Hand eczema in children referred for patch testing: North American Contact Dermatitis Group Data, 2000-2016.

BACKGROUND: Little is known about the aetiologies and relevant allergens in paediatric patients with hand eczema (HE). OBJECTIVES: To characterize the aetiologies and determine the proportion of positive and currently relevant allergens in children/adolescents (age < 18 years) with HE referred for patch testing. METHODS: A retrospective analysis (2000-2016) of North American Contact Dermatitis Group data was performed. RESULTS: Of 1634 paediatric patients, 237 (14·5%) had involvement of the hands. Final physician diagnoses included allergic contact dermatitis (49·4%), atopic dermatitis (37·1%) and irritant contact dermatitis (16·9%). In multivariable logistic regression models, employment was the only association with increased odds of any HE or primary HE. Children with HE vs. those without HE had similar proportions of positive patch tests (56·1% vs. 61·7%; χ2 -test, P = 0·11). The five most common currently relevant allergens were nickel, methylisothiazolinone, propylene glycol, decyl glucoside and lanolin. In multivariable logistic regression models of the top 20 relevant allergens, HE was associated with significantly higher odds of currently relevant reactions to lanolin, quaternium-15, Compositae mix, thiuram mix, 2-mercaptobenzathiazole and colophony. The allergens with the highest mean significance-prevalence index number were methylisothiazolinone, carba mix, thiuram mix, nickel and methylchloroisothiazolinone/methylisothiazolinone. CONCLUSIONS: Children with HE who were referred for patch testing had a high proportion of positive patch tests, which was similar to the proportion found in children without HE. Children with HE had a distinct and fairly narrow profile of currently relevant allergens.

Comparative study of Finn Chambers and T.R.U.E. test methodologies in detecting the relevant allergens inducing contact dermatitis.

T.R.U.E. Test is a ready-to-use patch test system, which contains 23 allergens and is the only Food and Drug Administration-approved source of allergens currently commercially available in the United States. Previously, allergens dispersed in either petrolatum or water and designed to be applied utilizing Finn Chambers were also commercially available in the United States. During a 5-year study at the University of Kansas Medical Center, 167 patients were patch tested using both Finn Chamber and T.R.U.E. Test methodologies. Discordant positive reactions were examined for clinical relevance. The Finn Chamber methodology was superior in detecting clinically relevant allergies to fragrance mix, balsam of Peru, and thiuram mix. T.R.U.E. Test performed somewhat better than the Finn Chamber in detecting relevant allergic reactions to nickel, neomycin, and methylchloroisothiazolinone/methylisothiazolinone. Neither T.R.U.E. Test nor Finn Chamber methodologies performed optimally in detecting relevant allergies to formaldehyde and carbamates. Practitioners limited to only the T.R.U.E. Test methodology need to be aware that relevant reactions to fragrances, rubber accelerators/pesticides (carbamates and thiurams), and formaldehyde may be missed with this system.

Lichenoid drug eruption to salsalate.

Cutaneous lichenoid eruptions can arise as a result of exogenous compound exposures. Pharmaceutical drugs, industrial compounds, and inhaled particles have been implicated as causative agents. To date, there have been no recorded cases of lichenoid drug eruptions (LDEs) caused by clinical use of the nonsteroidal anti-inflammatory drug salsalate. We describe a patient who experienced a lichenoid eruption after the initiation of salsalate for relief of arthritic pain. This eruption emerged after 1 month of therapy with salsalate, persisted for as long as salsalate was administered, and cleared within 3 weeks of discontinuing the medication. LDEs can clinically and histologically resemble idiopathic or classic lichen planus. Integrating drug history, clinical morphology, clinical distribution, and histopathology can aid in the differentiation. As in our patient's case, curative treatment for LDE requires discontinuation of the drug.

Role of body piercing in the induction of metal allergies.

BACKGROUND: Metal allergies have been linked to body piercing in women, but few studies have explored this phenomenon in men. It has been postulated that nickel/cobalt and nickel/palladium exhibit coreactivity in patients allergic to metals. OBJECTIVES: (1) Determine the incidence rate and the source for the induction of metal allergy in 3 groups of men: unpierced, one site-pierced, and multiple sites-pierced; and (2) evaluate the degree of coreactivity between nickel/cobalt and nickel/palladium. METHODS: Men aged 18 to 43 years (n = 118) were patch-tested using the North American Contact Dermatitis Group's protocol to nickel sulfate 2.5%, gold sodium thiosulfate 0.5%, cobalt chloride 1%, and palladium chloride 1%. RESULTS: Eleven (9.3%) subjects had at least 1 positive reaction. When characterized by the number of pierced sites, positive reactions were seen in 2 of 50 (4.0%) unpierced, 3 of 27 (11.1%) one site-pierced, and 6 of 41 (14.6%) multiply pierced men. The number of piercings was a statistically significant predictor of metal allergy (P = .04). Four (66.7%) cobalt and no palladium reactions occurred in nickel-positive subjects. The source for the induction of the allergic response was primarily jewelry, which accounted for 5 of 6 nickel allergies and 2 of 3 gold allergies. Silver jewelry was a significant predictor of an allergic response. CONCLUSION: This study represents the first report that the number of body piercings has positive bearing on the incidence of metal allergy in men. The data also support the theory of coreactivity for nickel/cobalt, but not for nickel/palladium.

Patch testing discordance alert: false-negative findings with rubber additives and fragrances.

From July 1996 through June 1998, the North American Contact Dermatitis Group evaluated 318 patients for suspected contact dermatitis by patch testing simultaneously with Finn Chambers and the T.R.U.E. Test allergen system. Discrepancies between the two systems were found in some of the results, particularly with fragrance and rubber allergens. These results suggest that positive reactions to fragrance, thiuram, and carba mix allergens may be missed if the T.R.U.E. Test is used alone.

Thimerosal in the detection of clinically relevant allergic contact reactions.

Thimerosal, a mercuric derivative of thiosalicylic acid, is a preservative used in several types of consumer products, including cosmetics, ophthalmic and otolaryngologic medications, and vaccines. As a result of allergic reactions and environmental concerns, its use has declined significantly during the past 2 decades. During a 5-year study at the University of Kansas Medical Center, 574 patients were patch tested to the North American Contact Dermatitis Group's standard allergen tray, which included thimerosal. The demographic data from thimerosal-allergic and nonallergic persons were compared. Statistically significant increases in thimerosal allergy were found among women, health care workers, secretaries, and cooks. Thimerosal-allergic persons were more likely to be allergic to neomycin, bacitracin, and tixocortol pivalate. Despite a high percentage of thimerosal-allergic patients in our test population, very few of these allergic reactions were found to be clinically relevant to the patient's current dermatologic condition. Using the Significance-Prevalence Index Number for thimerosal and contrasting this number with the Significance-Prevalence Index Number for other allergens on the North American Contact Dermatitis Group's standard tray, we propose that either ethyleneurea/melamine formaldehyde or bacitracin would be more useful than thimerosal as a commercially available screening allergen.

A preliminary report of the occupation of patients evaluated in patch test clinics.

BACKGROUND: The interplay between the occupational environment and worker's skin can result in contact dermatitis of both irritant and allergic types. Other forms of dermatitis can also be influenced by occupational exposures. OBJECTIVE: The aim of this study is to compare the occupations and allergens of occupational contact dermatitis cases with nonoccupational contact dermatitis cases. METHODS: Diagnostic patch testing with allergens of the North American Contact Dermatitis Group and occupational coding by the National Institute for Occupational Safety and Health methods. RESULTS: Of 2,889 patients referred for evaluation of contact dermatitis, 839 patients (29%) were found to have occupational contact dermatitis. Of the 839 cases deemed occupational, 455 cases (54%) were primarily allergic in nature and 270 cases (32%) were primarily irritant in nature. The remaining 14% were diagnoses other than contact dermatitis, aggravated by work. The occupation most commonly found to have allergic contact dermatitis was nursing. Allergens strongly associated with occupational exposure were thiuram, carbamates, epoxy, and ethylenediamine. CONCLUSION: Some contact allergens are more commonly associated with occupational contact dermatitis. Nursing and nursing support are occupations most likely to be overrepresented in contact dermatitis clinics.

Appearance of Langerhans cells in the epidermis of Tgfb1(-/-) SCID mice: paracrine and autocrine effects of transforming growth factor-beta 1 and -beta 2(1).

A striking immunologic abnormality of normal and SCID Tgfb1(-/-) mice is the total absence of Langerhans cells in their epidermis. Here we show that transfer of Tgfb1(+/-) SCID bone marrow causes, within a few weeks, the appearance of Langerhans cells in the epidermis of gamma-irradiated and unirradiated Tgfb1(-/-) SCID recipients. In addition, local injection of 2 x 10(5) latent transforming growth factor-beta1 cDNA-transduced cloned CD4+ T lymphocytes causes the appearance of Langerhans cells in the ear epidermis of Tgfb1(-/-) SCID mice. This effect is enhanced by antigen-specific activation of these T cells. Injection of recombinant active transforming growth factor-beta 2 into the ear of Tgfb1(-/-) SCID mice also results in the migration of Langerhans cells into the epidermis locally, but no epidermal Langerhans cells are seen after systemic injections of transforming growth factor-beta 2. Our results suggest that transforming growth factor-beta can act in paracrine as well as autocrine fashion to induce the differentiation of precursors into Langerhans cells. Furthermore, these results indicate that the relative roles of different transforming growth factor-beta isoforms in vivo may be influenced by their local availability and/or the regulation of their conversion from latent into active form.

Allergic contact dermatitis from glutaraldehyde in health-care workers.

Glutaraldehyde is considered the disinfectant of choice for sterilizing medical and dental equipment. Unfortunately, glutaraldehyde has many toxic side-effects, including the ability to induce allergic contact dermatitis. In a 5-year study at the University of Kansas, 468 patients were patch tested to glutaraldehyde. A comparison of results was made between those employed in a healthcare related field and those who were not. Health-care workers (HCWs) were more than 8x more likely to be allergic to glutaraldehyde than their non-health-care working peers (NHCWs). Statistically significant differences between HCWs and NHCWs were seen in their reactivity to glutaraldehyde, thimerosal, benzalkonium chloride and methyl methacrylate. A higher than expected co-reactivity between glutaraldehyde and formaldehyde was also noted among HCWs and NHCWs, which cannot fully be explained by concomitant exposure. Allergic contact dermatitis from glutaraldehyde often causes persistent dermatitis, which frequently forces patients to leave their jobs. Although the National Institute of Occupational Safety and Health has published guidelines for safe handling of glutaraldehyde, allergy appears to continue to rise, especially among those employed in health-care professions. Until a less sensitizing disinfectant is developed, it is in the best interest of those in health-care professions, and other professions exposed to glutaraldehyde, to heighten occupational safety standards and to improve methods of barrier protection.

Allergic contact dermatitis to gold.

Gold is a relatively common allergen that appears to induce dermatitis about the face and eyelids, as well as at sites of direct cutaneous contact. In this study, 355 patients with suspected contact dermatitis were evaluated; 17 (4.8%) were found to be allergic to gold. Fifteen of these 17 patients were re-evaluated at > 2 months after patch testing. When contact with gold jewelry was discontinued, 7 of 15 (46.7%) of the gold-allergic patients reported that their dermatitis cleared. In 3 of 7 patients (42.9%), discontinuing contact with gold jewelry was the only modification to their behavior; whereas in 4 of 7 (57.1%), discontinuing contact with gold jewelry and other documented allergens was necessary to affect resolution. Despite continuous contact with gold (jewelry and/or dental appliances), 7 of 15 (46.7%) of our patients had complete clearing of their symptoms by avoiding other documented allergens. None of our patients required the removal of dental gold.

The diagnostic evaluation, treatment, and prevention of allergic contact dermatitis in the new millennium.

Identifying the etiology of allergic contact dermatitis is a rewarding yet challenging endeavor. Not all allergic contact reactions are eczematous in appearance. The most reliable clinical clue to the allergic nature of the dermatitis is its geographic distribution. Once a list of culprit allergens has been identified by patch testing, the practitioner must identify the relevant allergen(s) and counsel the patient in avoidance. For most individuals, allergen avoidance results in resolution of the dermatitis; however, some patients will require continuing symptomatic therapy despite avoidance. For those patients unable to avoid known allergens, immunosuppressant therapies (including phototherapy) or barriers can be beneficial. Currently, hyposensitization is not a viable alternative for the treatment of allergic contact dermatitis.

Fungal contamination of outpatient examination rooms: is your office safe?

Dermatophyte and nondermatophyte fungi are ubiquitious in the envionment. This study demonstates the presence of dermatophyte fungi and saprophytic fungi contaminating step stools and flooring samples in office examination rooms. The use of protective coverings as well as other barriers will help to protect both patients and health care workers from acquiring nosocomial infection.

A sherlockian approach to contact dermatitis.

Identifying the etiology of allergic contact dermatitis requires detective work. Not all allergic reactions are eczematous in appearance. The most reliable clinical clue to the allergic nature of the dermatitis is its geographic distribution. Patch testing provides the list of culprit allergens. The mystery is solved when the suspected allergen is found to be relevant and the patient has been adequately instructed in allergen avoidance.

North American Contact Dermatitis Group patch test results for the detection of delayed-type hypersensitivity to topical allergens.

BACKGROUND: Allergic contact dermatitis is a significant cause of cutaneous disease affecting many individuals. Patch testing, when used properly, often provides support for the diagnosis of allergic contact dermatitis. OBJECTIVE: This article reports patch testing results from July 1, 1994, to June 30, 1996, by the North American Contact Dermatitis Group (NACDG). METHODS: Patients evaluated in our patch test clinics were tested with the same screening series of allergens by the use of a standardized patch testing technique. The data from these patients were recorded on a standard computer entry form and analyzed. RESULTS: Forty-nine allergens were tested on 3120 patients. Budesonide was added to the series in July 1995 and tested on 1678 patients. Of these patients, 66.5% had positive allergic patch test reactions, and 57% had at least one allergic reaction that was felt to be clinically relevant to the present or past dermatitis. The 20 screening allergens commercially available to United States dermatologists in the Allergen Patch Test Kit, accounted for only 54.1% of the patients with positive allergic reactions. The additional 30 allergens on the NACDG screening series accounted for 47% of patients with positive allergic reactions. Had the Allergen Patch Test Kit alone been used, 12.4% of all patients tested may have had their disease misclassified as a nonallergic disorder, and an additional 34.4% of all tested patients would not have had their allergies fully defined. Among those patients with positive responses to the supplemental allergens, 81% of the responses were of present or past relevance. The 12 most frequent contact allergens were nickel sulfate, fragrance mix, thimerosal, quaternium-15, neomycin sulfate, formaldehyde, bacitracin, thiuram mix, balsam of Peru, cobalt chloride, para-phenylenediamine, and carba mix. The present relevance varied with the specific allergen from 10.7% (thimerosal) to 85.7% (quaternium-15). Among newer allergens, methyldibromoglutaronitrile/phenoxyethanol (cosmetic preservative) caused positive allergic reactions in 2% of the patients; tixocortol-21-pivalate and budesonide (corticosteroids), in 2.0% and 1.1% of the patients, respectively; and ethylene urea/melamine formaldehyde mix (textile resin), in 5% of the patients. CONCLUSION: The usefulness of patch testing is enhanced with the number of allergens tested, because allergens not found on the commercially available screening series in the United States frequently give relevant allergic reactions.

Carbamazepine-induced pseudolymphoma with CD-30 positive cells.

A 44-year-old woman known to be allergic to phenytoin was treated with carbamazepine for 1 month and developed fever, lymphadenopathy, pneumonitis, hepatitis, and a morbilliform eruption. A skin biopsy specimen showed atypical lymphocytes in the dermis that were CD-3+, CD-30+, and L26-. T-cell gene rearrangement studies were negative. A diagnosis of anticonvulsant hypersensitivity syndrome with histologic features of a pseudolymphoma was made and her illness quickly improved after carbamazepine was discontinued. This case was typical of the anticonvulsant hypersensitivity syndrome and demonstrated cross-reactivity among the aromatic anticonvulsants. However, to our knowledge, this represents the first report of a carbamazepine-induced hypersensitivity with histologic features of a cutaneous pseudolymphoma, including CD-30+ cells.