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.

Contact allergenic potency: correlation of human and local lymph node assay data.

BACKGROUND: Effective toxicologic evaluation of skin sensitization requires that potential contact allergens are identified and that the likely risks of sensitization among exposed populations are assessed. By definition, chemicals that are classified as contact sensitizers have the capacity to cause allergic contact dermatitis (ACD) in humans. However, this hazard is not an all-or-nothing phenomenon; clear dose-response relationships can be discerned and thresholds identified for both the induction of sensitization and the elicitation of ACD. Commonly, these parameters are grouped under the heading of potency, the determination of which is vital for risk assessment. Preclinical testing for sensitization potential is critically important for hazard assessment before human exposure. The murine local lymph node assay (LLNA) is the most recently accepted test method for sensitization hazard assessment. OBJECTIVE: The aim was to compare potency estimations derived from LLNA data with clinical determinations of relative potency based on human data. METHODS: No-effect levels (NOELs) for a range of 21 chemicals were determined from nondiagnostic human repeat patch test studies as reported in the literature. These levels were compared with LLNA EC(3) values, the estimated concentration required to produce a 3-fold increase (positive response) in draining lymph node cell (LNC) proliferative activity. RESULTS: Using available human repeat patch test data, together with expert judgment, the compounds were classified as strong, moderate, weak, extremely weak, or nonsensitizing. Additionally, the potency of each chemical was classified independently based on its LLNA EC(3) value. The results show clearly that LLNA EC(3) values are very comparable with the NOELs calculated from the literature. Moreover, the potency rankings based upon LLNA EC(3) data support their human classification. CONCLUSION: The present investigations show that the LLNA can be used to provide quantitative estimates of relative skin sensitizing potency EC(3) values that correlate closely with NOELs established from human repeat patch testing and from our clinical experience.

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.

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.

Use of mycophenolate mofetil in the treatment of paraneoplastic pemphigus.

Paraneoplastic pemphigus (PNP) is a rare autoimmune blistering disease with circulating antibodies that bind the cell surface of the epidermis and other non-stratifying epithelia, and immunoprecipitate a complex of four or five proteins (250 kDa, 230 kDa, 210 kDa, 190 kDa and occasionally 170 kDa).1,2 Combinations of immunosuppressive agents are usually required to obtain even partial control of the skin lesions.3 Mucous membrane lesions are refractory to treatment. We describe a patient with PNP whose skin and oral lesions are quiescent following treatment with oral mycophenolate mofetil.

Pemphigus foliaceus successfully treated with mycophenolate mofetil as a steroid-sparing agent.

Pemphigus foliaceus is an autoimmune blistering disease of unknown origin with antibodies produced against desmoglein 1, an adhesive protein found in the desmosomal cell junction in the suprabasal layers of the epidermis. The disease is primarily treated with corticosteroids and corticosteroid-sparing immunosuppressive agents. We report a case of pemphigus foliaceus successfully treated with mycophenolate mofetil. It remains to be seen whether this agent has a significant effect on the course of the disease and remission induction.

Prevention of sodium lauryl sulfate irritant contact dermatitis by Pro-Q aerosol foam skin protectant.

Eczematous skin disease is a serious work-related illness. Since 1995, reimbursement by insurance companies for treatment of skin diseases has become the largest cost source in some countries. This study was a randomized controlled trial (N = 20) of the efficacy of Pro-Q, a skin protectant product, in the prevention of contact dermatitis from sodium lauryl sulfate and urushiol, the resinous sap of poison ivy and poison oak. Pro-Q was significantly effective in reducing the irritation from sodium lauryl sulfate but did not prevent the allergic reaction to urushiol.

An environmental hazard assessment of low-level dermal exposure to hexavalent chromium in solution among chromium-sensitized volunteers.

To evaluate the potential for elicitation of allergic contact dermatitis from contact with standing water in the environment, 26 persons known to be allergic to hexavalent chromium [Cr(VI)] were exposed to 25 to 29 mg/L Cr(VI) by immersion of one arm for 30 minutes per day on 3 consecutive days in a potassium dichromate bath. Sixteen of the 26 volunteers demonstrated either no or an equivocal response to the Cr(VI) challenge. Ten of the volunteers developed a few papules or vesicles (1 to approximately 15), mild redness, and pruritus on the Cr(VI)-challenged arm. Histopathological examination of the papules revealed spongiosis and perieccrine and perivascular inflammation. The responses were diagnosed as acute perieccrine reactions. It was concluded that exposure to similar concentrations of Cr(VI) in the environment does not pose an allergic contact dermatitis hazard, even to Cr-sensitized persons.

Sweet's syndrome and erythema nodosum: the simultaneous occurrence of 2 reactive dermatoses.

BACKGROUND: The simultaneous occurrence of Sweet's syndrome (SS) and erythema nodosum (EN) in 1 patient is rare. Our review of the literature revealed only 11 biopsy-proved cases in which the 2 reactive dermatoses occurred together. None were associated with an underlying malignant neoplasm. OBSERVATIONS: We report a biopsy-proved case of SS and EN occurring simultaneously in a patient with an underlying malignant neoplasm (specifically, acute myelogenous leukemia). We also report another biopsy-proved case of SS and EN occurring simultaneously in a patient with underlying Crohn's disease. CONCLUSIONS: The simultaneous occurrence of SS and EN in 1 patient is rarely reported. Both disorders are reactive dermatoses that share many overlapping features. Although individually distinctive, SS and EN are also part of a growing continuum of reactive dermatoses. Our expanded understanding of the similarities and simultaneous manifestation of SS and EN may help us in the future to identify a common underlying mechanism of pathogenesis.

Allergic contact dermatitis to preservatives in topical medicaments.

BACKGROUND: Formaldehyde-releasing preservatives are well-known allergens found in many topical preparations including medications. OBJECTIVE: To analyze the relevance of a positive patch test to formaldehyde-releasing preservatives in medications containing these preservatives. METHODS: Patients were recruited with a history of allergy to one of these preservatives. Patch and use testing to the medications, vehicles, and preservatives were performed. The following medications and their respective preservatives were used: Renova 0.05% cream/quaternium-15, Dovonex 0.005% cream/diazolidinyl urea, and Temovate-E 0.05% cream/diazolidinyl urea. RESULTS: Nine patients participated in the study. A positive patch test to the preservative was reproduced in six of nine patients, and a questionable reaction occurred in one. Two patients had a positive patch test to the topical medication and one a questionable reaction. There were no definitive positive patch tests to the vehicle but two questionable ones. Use testing revealed three positive reactions to Renova, one to Renova vehicle, and one to Temovate-E vehicle. CONCLUSIONS: The concentration of the preservative in the commercial preparation was often below the threshold necessary to produce a clinical reaction. Use testing is a valuable tool in the complete evaluation of the patient with a positive patch test to a formaldehyde-releasing perservative found in topical medication.

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.

Prevalence of occupationally related hand dermatitis in dental workers.

Occupationally related hand dermatitis has been attributed to frequent hand-washing, exposure to possible sensitizers and latex glove use. The authors conducted a study to determine the prevalence of occupationally related hand dermatitis in dental personnel. They found that 75 (19.2 percent) of 390 subjects self-reported they had a positive history of hand dermatitis. Further testing of 53 of these subjects indicated that only 9.4 percent reacted to the 45 allergens tested, and 3.8 percent had an allergy to latex.

Treatment of poison ivy/oak allergic contact dermatitis with an extract of jewelweed.

BACKGROUND: Jewelweed (Impatiens biflora) is a plant which has been used for centuries for the treatment of poison ivy/oak allergic contact dermatitis. Numerous claims for its effectiveness exist in the lay press, and over-the-counter medicaments containing jewelweed are reputed to be an effective remedy for poison ivy/oak dermatitis. Despite these claims, few scientific studies testing the effectiveness of jewelweed have been performed. OBJECTIVE: Our objective in this pilot study was to test the efficacy of an extract of jewelweed in the treatment of experimentally induced allergic contact dermatitis to poison ivy/oak. METHODS: A randomized, double-blinded, paired comparison investigation was performed. Ten adult volunteers were patch tested to urushiol, the allergenic resin in poison ivy/oak. For each volunteer, one patch test site was treated with an extract prepared from the fresh stems of jewelweed; the remaining site was treated with distilled water to serve as a control. Sites were examined on days 2, 3, 7, and 9 with reactions graded on a numerical scale. RESULTS: All subjects developed dermatitis at each patch test site. There was no statistically significant difference in the objective scores at the sites treated with jewelweed extract versus the distilled water control sites. CONCLUSION: This study demonstrated that an extract of jewelweed was not effective in the treatment of poison ivy/oak allergic contact dermatitis.

Betaxolol-associated hyperpigmentation of the fingers in a patient with unrelated contact dermatitis.

Betaxolol ophthalmic solution has been associated with periocular skin hyperpigmentation. We report a case of a woman with hyperpigmentation of the fingers associated with oral betaxolol. Based on case reports associated with the topical ophthalmic product, we believe the hyperpigmentation was likely caused by oral betaxolol.

Dermatoses among housekeeping personnel.

BACKGROUND: Housekeepers are exposed to irritants and allergens in their work and are at significant risk for developing occupationally induced contact dermatitis. OBJECTIVE: We studied housekeepers at the Hershey Medical Center to determine the cause and frequency of contact dermatitis and contact urticaria in these workers. METHODS: All housekeepers were examined. Those with hand dermatitis had an extensive history, patch testing, and latex RAST testing. RESULTS: Eight of 130 had hand dermatitis. None had a relevant positive patch test or positive RAST test. CONCLUSIONS: Of our housekeepers, 6.2% had occupationally induced irritant contact dermatitis. None had allergic contact dermatitis or contact urticaria to latex.