Contact allergy to haptens in the Swedish baseline series: Results from the Swedish Patch Test Register (2010 to 2017).

BACKGROUND: Allergic contact dermatitis has considerable public health impact and causative haptens vary over time. OBJECTIVES: To report the prevalence of contact allergy to allergens in the Swedish baseline series 2010 to 2017, as registered in the Swedish Patch Test Register. METHODS: Results and demographic information for patients tested with the Swedish baseline series in 2010 to 2017 were analysed. RESULTS: Data for 21 663 individuals (females 69%) were included. Females had significantly more positive patch tests (54% vs 40%). The reaction prevalence rates were highest for nickel sulfate (20.7%), fragrance mix I (7.1%), Myroxylon pereirae (6.9%), potassium dichromate (6.9%), cobalt chloride (6.8%), methylchloroisothiazolinone/methylisothiazolinone (MCI/MI; 6.4%), MI (3.7%), colophonium (3.5%), fragrance mix II (3.2%), and formaldehyde (3.2%). Myroxylon pereirae reaction prevalence increased from 5% in 2010 to 9% in 2017 and that for methyldibromo glutaronitrile from 3.1% to 4.6%. MCI/MI and MI reactions decreased in prevalence after 2014. Nickel reaction prevalence decreased among females aged 10 to 19 years. CONCLUSIONS: Nickel remains the most common sensitizing agent, with reaction prevalence decreasing among females younger than 20 years. The changes in MCI/MI and MI reaction prevalence mirrored those in Europe. The register can reveal changes in contact allergy prevalence over time among patients patch tested in Sweden.

Suitable test concentration of cobalt and concomitant reactivity to nickel and chromium: A multicentre study from the Swedish Contact Dermatitis Research Group.

BACKGROUND: In Sweden, cobalt chloride 0.5% has been included in the baseline series since the mid-1980s. A recent study from Stockholm showed that cobalt chloride 1% petrolatum (pet.) was more suitable than 0.5%. Cobalt chloride at 1.0% has been patch tested for decades in many European countries and around the world. OBJECTIVES: To study the suitability of patch testing to cobalt 1.0% vs 0.5% and to analyze the co-occurrence of allergy to cobalt, chromium, and nickel. RESULTS: Contact allergy to cobalt was shown in 90 patients (6.6%). Eighty (5.9%) patients tested positive to cobalt 1.0%. Thirty-seven of the 90 patients (41.1%) with cobalt allergy were missed by cobalt 0.5% and 10 (0.7%) were missed by cobalt 1.0% (P < .001). No case of patch test sensitization was reported. Allergy to chromium was seen in 2.6% and allergy to nickel in 13.3%. Solitary allergy to cobalt without nickel allergy was shown in 61.1% of cobalt-positive individuals. Female patients had larger proportions of positive reactions to cobalt (P = .036) and nickel (P < .001) than males. CONCLUSION: The results speak in favor of replacing cobalt chloride 0.5% with cobalt chloride 1.0% pet. in the Swedish baseline series, which will be done 2021.

Can patch testing with methylchloroisothiazolinone/methylisothiazolinone be optimized using a new diagnostic mix? - A multicenter study from the Swedish Contact Dermatitis Research Group.

BACKGROUND: Methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) and methylisothiazolinone (MI) are tested to detect contact allergy to these isothiazolinones. OBJECTIVES: To study if an aqueous patch test preparation with MCI and MI in a mix of 0.015% and 0.2%, respectively, detects more contact allergies than the commonly used preparations of MCI/MI in 0.02% aq. and MI in 0.2% aq. METHODS: A total of 1555 patients with dermatitis in five Swedish dermatology departments were tested consecutively with MCI/MI 0.215% aq., MCI/MI 0.02% aq., and MI 0.2% aq. RESULTS: The share of contact allergy to MCI/MI 0.215% aq., MCI/MI 0.02% aq., and MI 0.2% aq. varied in the test centers between 7.9% and 25.9%, 3.2% and 10.3%, and 5.8% and 12.3%, respectively. MCI/MI 0.215% aq. detected significantly more patch-test positive individuals than both MCI/MI 0.02% aq. (P < .001) and MI 0.2% aq. (P < .001), as well as either one of MCI/MI and MI (P < .001). In the patients only reacting to MCI/MI 0.215% aq., 57.7% were recorded as having a dermatitis that was explained or aggravated by exposure to either MCI/MI or MI. CONCLUSION: The results speak in favor of replacing the preparations MCI/MI 0.02% aq. and MI 0.2% aq. with MCI/MI 0.215% aq. as the screening substance in the Swedish baseline series, which has been implemented in 2020.

Contact allergy to citral and its constituents geranial and neral, coupled with reactions to the prehapten and prohapten geraniol.

BACKGROUND: Citral is commonly used as a fragrance and flavor material and consists of the aldehydes geranial and neral. Citral is included in fragrance mix (FM) II. Geranial and neral have also been identified in autoxidation of geraniol, a fragrance compound present in FM I. OBJECTIVES: To study contact allergy to citral, geranial, and neral, and concomitant reactivity to oxidized geraniol and fragrance markers of the baseline series. METHODS: A total of 1476 dermatitis patients with suspected allergic contact dermatitis were patch tested using geranial, neral, and citral, all 3.5% petrolatum (pet.) as well as geraniol 6.0% and oxidized geraniol 11% pet. in addition to the Swedish baseline series. RESULTS: Frequencies of positive reactions to citral, geranial, and neral were 2.9%, 3.4% and 1.9%, respectively. Together, citral and geranial gave 4.2% positive patch test reactions in consecutive dermatitis patients. In patients with positive reactions to citral or its components, 25% to 34% reacted to FM II and 61% reacted to oxidized geraniol. CONCLUSIONS: Patch testing with citral, its components, or oxidized geraniol detects contact allergic reactions not detected using the baseline series. Patch testing with pure geraniol was shown to be of little value. Geranial and neral, although closely chemically related, are concluded to be separate haptens.

Patch Testing with a New Composition of Mercapto Mix: A Multi-centre Study by the Swedish Contact Dermatitis Research Group.

This study investigated whether more patients with contact allergies were detected by patch testing with mercapto mix with a higher concentration of 2-mercaptobenzothiazolinone (MBT) than the commonly used mercapto mix. A total of 3,143 dermatitis patients in 5 Swedish dermatology departments were patch- tested with 3 mercapto test preparations: MBT 2.0% petrolatum (pet.); mercapto mix 2.0% pet.; and mercapto mix 3.5% pet. Positive reactions to these mercapto mixes varied between 0-0.50%, 0-0.93%, and 0-1.4%, respectively, in the 5 centres. Numerically, mercapto mix 3.5% pet. detected all positive patients and more patch-test positive patients than did the 2 other substances, but the difference was not statistically significant. The authors recommend replacing mercapto mix 2.0% pet. in the Swedish baseline series with mercapto mix 3.5% pet., since the latter also detected those patients who would have been missed because MBT 2.0% is not included in the Swedish baseline series.

Psychological symptoms and self-image of patients with complaints attributed to dental restorative materials.

OBJECTIVES: The aim was to study self-image and the level of psychological symptoms in patients with symptoms attributed to their dental restorative materials. MATERIALS AND METHODS: A questionnaire containing questions regarding dental and medical history was answered by 257 participants, one group with local oral symptoms only (LSO), and one group with multi-symptoms (M-S). A reference group was randomly selected from a research database at the Department of Psychology, Umeå University, Sweden. The self-image was assessed using the Structural Analysis of Social Behavior (SASB). Psychological symptoms such as somatization, depression, and anxiety were assessed using the Symptom Check List 90 (SCL-90) and the Global Severity Index (GSI) was used to determine the level of psychological symptoms. RESULTS: SASB showed that the M-S group and the LSO-group scored significantly higher on the "spontaneous" and "positive self-image" than the reference group. In the SCL-90, the M-S group scored significantly higher than the LSO-group and the references on the somatization subscales. On depression, anxiety, and the GSI scale, the M-S group scored significantly higher than the reference group. CONCLUSIONS: The two subgroups scored significantly higher on the SASB Spontaneous and Positive clusters which indicates that these patients have an excessively positive self-image, are very spontaneous and have an overconfidence in themselves compared to the reference group. In the M-S group there was a clear tendency to somatization, depression, and anxiety and they were more psychologically stressed than the reference group. CLINICAL RELEVANCE: Among the patients with illness attributed to their dental materials, the M-S-patients had a significantly higher level of general psychological distress and somatization than the control group which may lead to mental stress.

Lived Experiences of Patients Suffering from Acute Old World Cutaneous Leishmaniasis: A Qualitative Content Analysis Study from Iran.

BACKGROUND: The aim of this study was to explore the experiences of patients who suffer from acute cutaneous leishmaniasis in Iran, focusing on quality of life. METHODS: The study was conducted at two different sites in Iran in 2010-2011. Individual in-depth interviews were conducted with six men and six women parasitologically confirmed acute cutaneous leishmaniasis. Interviews were recorded, transcribed verbatim, and translated into English. Qualitative content analysis was used for data analysis. RESULTS: The participants, aged 23 to 63yr, had mild to severe disease. Based on the analysis four main themes were developed. "Fearing an agonizing disease" reflects patients' experiences of disease development resulting in sadness and depression, "struggling to cope" and "taking on the blame" both illustrate how patients experience living with the disease, which included both felt and enacted stigma as major social concerns. "Longing for being seen and heard" refers to patients' experiences with healthcare as well as their expectations and demands from communities and healthcare to be involved in closing the knowledge and awareness gap. CONCLUSION: Mental and social dimensions of cutaneous leishmaniasis were complex and adversely affected patients' lives by causing psychological burden and limiting their social interactions. Health authorities have to plan programs to increase the disease awareness to prevent the existing stigma to improve patients' social condition and medical care.

Contact allergy to oxidized geraniol among Swedish dermatitis patients-A multicentre study by the Swedish Contact Dermatitis Research Group.

BACKGROUND: Geraniol is a widely used fragrance terpene, and is included in fragrance mix I. Geraniol is prone to autoxidation, forming the skin sensitizers geranial, neral, and geraniol-7-hydroperoxide. Oxidized geraniol has previously been patch tested in 1 clinic, giving 1% to 4.6% positive reactions in consecutive patients when tested at 2% to 11%. AIM: To compare test reactions to pure and oxidized geraniol, to compare 2 different test concentrations of oxidized geraniol and to investigate the pattern of concomitant reactions to fragrance markers of the baseline series in a multicentre setting. METHODS: One thousand four hundred and seventy-six consecutive patients referred for patch testing were patch tested with geraniol 6% pet. and oxidized geraniol 6% and 11% pet. RESULTS: Pure geraniol 6% pet., oxidized geraniol 6% pet. and oxidized geraniol 11% pet. gave 1%, 3% and 8% positive patch test reactions and 0.7%, 3% and 5% doubtful reactions, respectively. Approximately 50% of the patients with doubtful reactions to oxidized geraniol 6% pet. had positive reactions to oxidized geraniol 11% pet. CONCLUSIONS: Oxidized geraniol 11% pet. provides better detection than oxidized geraniol 6% pet. As most patients reacted only to oxidized geraniol, it is important to explore further whether oxidized geraniol should be included in a baseline patch test series.

Scoring of Hand Eczema: Good Reliability of Hand Eczema Extent Score (HEES).

There is good agreement between dermatological staff and patients using the Hand Eczema Extent Score (HEES). The aim of this study was to assess inter- and intra-observer reliability of the HEES in dermatologists and intra-observer reliability of the HEES in patients with hand eczema. Six dermatologists assessed 18 patients twice. Only the hands of the patients were visible to the assessors. Patients performed a self-assessment twice. Inter- and intra-observer reliability was tested with intraclass correlation coefficient (ICC). The mean HEES score for all dermatologists' assessments was 21.0 (range 3.6-46.3). The corresponding mean scores for all patients' own assessments were 24.9 (range 4.0-54.0). Inter-observer reliability in the dermatologists' observations ICC classification was very good, median value 0.82 (range 0.56-0.92). The overall intra-observer reliability for the 6 dermatologists' ICC classification was very good (range 0.88-0.94). Intra-observer reliability in the patients' 2 self-assessments ICC classification was very good (ICC 0.95). In conclusion, HEES is a reliable tool for both dermatologists and patients to grade the extent of hand eczema.

Patch testing with hydroxyisohexyl 3-cyclohexene carboxaldehyde (HICC) - a multicentre study of the Swedish Contact Dermatitis Research Group.

BACKGROUND: In 2014, the fragrance hydroxyisohexyl 3-cyclohexene carboxaldehyde (HICC) was excluded from the Swedish baseline series. OBJECTIVES: To study (i) whether fragrance mix (FM) II with 5% HICC detects more positive reactions than usual FM II with 2.5% HICC, and (ii) the reproducibility of patch testing with HICC. METHODS: Two thousand one hundred and eighteen dermatitis patients at five Swedish dermatology departments were consecutively tested with FM II 14% pet., FM II 16.5% pet., and duplicate preparations of HICC 5% pet. RESULTS: Of the patients, 3.2% reacted to FM II 14%, and 1.5% reacted to HICC. Separate testing with HICC detected 0.3% reactions without concomitant reactivity to FM II. FM II with 5% HICC did not give rise to more irritant reactions or signs of active sensitization than FM II with 2.5% HICC. Patch testing with duplicate applications of HICC increased the overall prevalence of HICC contact allergy to 1.9%. CONCLUSION: FM II with 5% HICC does not detect more positive reactions than FM II with 2.5% HICC. Separate testing with HICC does not detect a sufficient proportion of patients who react only to HICC, without concomitant reactions to FM II, to warrant its inclusion in a baseline series.

Experience of living with nonspecific building-related symptoms.

Nonspecific building-related symptoms (NBRS) is a combination of general, skin and mucosal symptoms related to certain buildings. Despite high prevalence in the general population and severe symptomatology in certain cases there is no scientific documentation of quality of life in NBRS. The purpose of this study was to illuminate how individuals with NBRS experience daily life. Data were collected through descriptive, written texts and through telephone interviews with 11 individuals diagnosed with NBRS, and qualitative content analysis was conducted. Three main content areas were identified: (1) attitudes from the surrounding (categories: being questioned and lack of understanding from others; from zero to full support); (2) consequences (difficulties with daily activities; financial difficulties; affecting family and friends; emotional consequences); and (3) coping (learning to accept and finding solutions; avoiding; struggling; finding the positive; making one's home a sanctuary). As a conclusion, NBRS may affect several aspects of daily life, resulting in considerable alterations, limitations and emotional impact for the afflicted person and his/her family. Both environmental factors and attitudes from the surrounding can contribute to this impact on daily life. Strategies needed to cope with this impact may include both problem-focused and emotion-focused strategies, such as struggling, avoiding trigger factors and finding positive aspects.

Is p-tert-butylphenol-formaldehyde resin (PTBP-FR) in TRUE Test® (Mekos test) sensitizing the tested patients?

BACKGROUND: In a population study using TRUE Test®, we noted late reactions to p-tert-butylphenol-formaldehyde resin (PTBP-FR) in 0.5% of subjects tested. OBJECTIVES: In order to explore possible test sensitization, differences in the contents of sensitizers within PTBP-FR in test preparations for TRUE Test® and Finn Chambers® were analysed. Subjects allergic to PTBP-FR and subjects with late reactions to PTBP-FR were retested in order to explore whether these groups reacted to different PTBP-FR sensitizers. PATIENTS/MATERIALS/METHODS: Four individuals with late reactions and 5 subjects with established allergy to PTBP-FR were retested with defined PTBP-FR sensitizers. PTBP-FR constituents in patches from TRUE Test® were analysed with high-performance liquid chromatography. Previously analysed samples of PTBP-FR constituents served as a reference. RESULTS: The pattern of reaction to PTBP-FR sensitizers was similar in both groups. Subjects with suspected sensitization had somewhat stronger reactions than controls. The concentrations of monomers, dimers and trimers were generally higher in the TRUE Test® resin than in reference substances. CONCLUSIONS: Retesting did not add information regarding causes of possible sensitization. Analysis showed that the resin used in TRUE Test® has a lower degree of polymerization or condensation, which may enhance its sensitizing properties. A follow-up of late reactions to PTBP-FR in TRUE Test® should be carried out.

Contact allergy trends in Sweden - a retrospective comparison of patch test data from 1992, 2000, and 2009.

BACKGROUND: Contact allergy prevalence rates change over time as a result of variations in allergen exposure. Data from patch test clinics are often used as markers for allergy trends. OBJECTIVES: The aim of the present retrospective study was to describe trends in rates of sensitization to allergens in the Swedish baseline series. PATIENTS/MATERIALS/METHODS: Prevalence rates are described by comparing consecutive patch test data from 1992, 2000 and 2009 in Swedish patch test clinics. In total, 3680 patients were included in 1992, 3825 in 2000, and 3112 in 2009. RESULTS: Among test substances with a sensitization rate above 2% in 2009, significant decreases were noted for nickel sulfate, cobalt chloride, colophonium, and methylchloroisothiazolinone (MCI)/methylisothiazolinone (MI), and a significant increase for p-phenylenediamine, as compared with 1992. Potassium dichromate reactions had increased among younger women, whereas reactions to nickel and cobalt had decreased in this group. Sensitization to chromium, cobalt and fragrance mix I had decreased among older men, and sensitization to nickel had decreased among younger men. CONCLUSIONS: It is probable that these changes in 1992-2009 reflect both changes in regulations for nickel, lower levels of chromium in cement and of MCI/MI in cosmetics, and increasing use of hair dyes.

Exposure to formaldehyde, nitrogen dioxide, ozone, and terpenes among office workers and associations with reported symptoms.

PURPOSE: To compare exposure to formaldehyde, nitrogen dioxide, ozone and terpenes among office workers with and without sick building syndrome and the odds ratio for exposure. Are there significant differences? METHODS: In this cross-sectional study of office workers, we investigated the associations between exposure to formaldehyde, nitrogen dioxide, ozone, α-pinene, and D-limonene using a case-control analysis. Data on perceived general, mucosal, and skin symptoms were obtained by questionnaires. Personal exposure measurements of the compounds were performed among cases and controls, and the odds ratios for exposures to the substances, both singly and in combination, were investigated. RESULTS: Exposures varied for formaldehyde between 0.23 and 45 µg/m(3), nitrogen dioxide between 0.26 and 110 µg/m(3), ozone between <16 and 165 µg/m(3), α-pinene between 0.2 and 170 µg/m(3), and D-limonene between 0.8 and 1,400 µg/m(3). No consistent differences in exposure odds ratios were found between cases and controls or for individual symptoms.

Patch testing with a textile dye mix in two concentrations - a multicentre study by the Swedish contact dermatitis research group.

UNLABELLED: Disperse dyes, which are used for colouring synthetic textile fibres, are well-known contact sensitisers. To investigate the outcome of patch-testing with a textile dye mix (TDM) at 7 dermatology clinics in Sweden, a TDM tested at 2 concentrations was included into the baseline series during one year. The mix consisted of Disperse (D) Blue 35, D Yellow 3, D Orange 1 and 3, D Red 1 and 17, all 1.0%, and D Blue 106 and D Blue 124, each 0.3% in the mix 6.6% and 1.0% each in the mix 8.0%. In 2,122 tested patients, contact allergy to the TDM at the concentration 8.0% was found in 2.8% and to the TDM at 6.6% in 2.5% of the patients. The contact allergy to the TDM could explain or contribute to the dermatitis in about 35% of the patients. CONCLUSION: contact allergy to the TDM is common and inclusion into the Swedish baseline series should be considered.

Swedish Experiences From Patch Testing Methylisothiazolinone Separately.

The preservative methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) is a well-known sensitiser and present in the Swedish baseline series since the 1980s. The proportions of MCI/MI are 3:1. MI alone has been used as a preservative since less than 10 years. This study was conducted on behalf of the Swedish Contact Dermatitis Research Group to evaluate inclusion of MI in the Swedish baseline series since the preparation of MCI/MI might fail to detect contact-allergic reactions to MI alone. Patients with suspected allergic contact dermatitis at 5 Swedish dermatology departments were consecutively patch tested with MI 2,000 ppm aq and MCI/MI 200 ppm aq. The number of cases with exclusive contact allergy to MI varied between 0.8-4.2%. In total, 1.9% reacted exclusively to MI and not to MCI/MI. Due to the considerable frequency of contact allergy to MI not traced by MCI/MI, MI 2,000 ppm aq is included in the Swedish baseline series from January 2014. This corresponds to a dose of 60 µg/cm2.

Brain responses to olfactory and trigeminal exposure in idiopathic environmental illness (IEI) attributed to smells -- an fMRI study.

OBJECTIVE: Idiopathic environmental intolerance (IEI) to smells is a prevalent medically unexplained illness. Sufferers attribute severe symptoms to low doses of non-toxic chemicals. Despite the label, IEI is not characterized by acute chemical senses. Theoretical models suggest that sensitized responses in the limbic system of the brain constitute an important mechanism behind the symptoms. The aim was to investigate whether and how brain reactions to low-levels of olfactory and trigeminal stimuli differ in individuals with and without IEI. METHODS: Brain responses to intranasally delivered isoamyl acetate and carbon dioxide were assessed in 25 women with IEI and 26 non-ill controls using functional magnetic resonance imaging. RESULTS: The IEI group had higher blood-oxygenated-level-dependent (BOLD) signal than controls in the thalamus and a number of, mainly, parietal areas, and lower BOLD signal in the superior frontal gyrus. The IEI group did not rate the exposures as more intense than the control group did, and there were no BOLD signal differences between groups in the piriform cortex or olfactory regions of the orbitofrontal cortex. CONCLUSIONS: The IEI reactions were not characterized by hyper-responsiveness in sensory areas. The results can be interpreted as a limbic hyperreactivity and speculatively as an inability to inhibit salient external stimuli.

Overlap in prevalence between various types of environmental intolerance.

Environmental intolerance (EI) is characterized by attribution of several, multisystem symptoms to specific environmental exposures, such as exposure to odorous/pungent chemicals, certain buildings, electromagnetic fields (EMFs) and everyday sounds. The symptoms are medically unexplained, non-specific and the symptoms overlap between different types of EI. To approach the issue of underlying mechanisms the matter of overlap in prevalence between intolerances can provide valuable information. The aim of the study was to examine if the overlap between intolerance to odorous/pungent chemicals, certain buildings, EMFs and sounds is larger than the expected overlap if no association would exist between them. The study was using cross-sectional data from the Västerbotten Environmental Health Study in Sweden; a large questionnaire-based survey. 8520 adults (18-79 years) were randomly selected after stratification for age and sex, of whom 3406 (40%) participated. Individuals with the four types of intolerance were identified either through self-report, or by having been physician-diagnosed with a specific EI. The overlaps between the four EIs were greater than predictions based on coincidence for both self-reported and diagnosed cases (except for the overlap between diagnosed intolerance to sounds and EMFs). The results raise the question whether different types of EI share similar underlying mechanisms, or at least that the sufferers of EI share some predisposition to acquire the conditions.

Patch testing with formaldehyde 2.0% in parallel with 1.0% by the Swedish contact dermatitis research group.

In a multicentre study consecutively patch-tested dermatitis patients were tested simultaneously with 1.0% and 2.0% (w/v) formaldehyde in aqua applied with a micropipette (15 µl) to the filter paper disc in Finn Chambers (0.30 mg/cm(2) and 0.60 mg/cm(2), respectively). A total of 2,122 dermatitis patients were patch-tested. In all, 77 (3.6%) patients reacted positively to formaldehyde; 37 reacted only to 2.0%, 35 reacted to both concentrations and 5 patients reacted only to 1.0%. Significantly more patients were thus diagnosed with contact allergy to formaldehyde with 2.0% compared to 1.0% (p < 0.001) without causing more irritant reactions. The detected number of isolated allergic reactions to the 2 formaldehyde-releasers in the Swedish baseline series and not to formaldehyde itself raises the question whether quaternium-15 1.0% and diazolidinyl urea 2.0% should be present in the Swedish baseline series.