Presentations to emergency departments in Melbourne, Australia diagnosed as allergic contact dermatitis.

BACKGROUND: This study investigated cases diagnosed as allergic contact dermatitis (ACD) in emergency departments (EDs) and management. METHODS: A multisite retrospective study of patients attending EDs in metropolitan Melbourne between July 2017 and June 2018 was performed. Using International Statistical Classification of Disease-10 (ICD-10) codes, the Victorian Agency for Health Information generated a list of cases of contact dermatitis (CD). Demographic and clinical data were analysed. RESULTS: Two hundred twenty-eighty patients from 14 different sites were diagnosed with ACD. Hair dyes caused the most cases, and one such case was admitted to hospital. It was apparent from the specified causes that cases of irritant CD were misdiagnosed as ACD. There were significant differences in management with dermatology input, with dermatologists more often advising oral corticosteroids (33.3% vs. 14.5%, P = 0.004) topical corticosteroids (92.9% vs. 38.7%, P < 0.01), emollients (38.1% vs. 20.4%, P = 0.01) and less often advising antihistamines (16.7% vs. 44.6%, P < 0.001). With dermatology input, potent or very potent steroids were more likely to be prescribed (69.3% vs. 11.1%, P < 0.001); without, a mild potency steroid was more likely to be prescribed (63.9% vs. 4%, P = 0.01). CONCLUSION: Improved understanding, diagnosis and management of CD are needed in EDs.

Hyperkeratotic flexural erythema (more commonly known as granular parakeratosis) with use of laundry sanitizers containing benzalkonium chloride.

BACKGROUND: Hyperkeratotic flexural erythema (HKFE), also known as granular parakeratosis, is a scaly, erythematous or brown eruption, which usually occurs in the intertriginous and flexural areas. It has been linked to the use of benzalkonium chloride (BAK). AIM: To review the clinical presentation of patients diagnosed with HKFE who had been exposed to laundry sanitizer containing BAK, and the therapies trialled to treat these patients. METHODS: This was a retrospective cases series of 45 patients seen by dermatologists in Victoria, Australia. Information was collected on clinical presentation, investigation and management. RESULTS: The patients varied in age from 18 months to 89 years. The rash typically presented as a symmetrical erythema with characteristic multilayered brownish epidermal scaling. The most common location of the rash was the inguinal/anogenital area (32 of 45 patients; 71.1%) and there was a female predominance. Regarding treatment, topical corticosteroids were frequently prescribed and antibiotics were trialled in 11 patients; however, the condition resolved spontaneously over time in all patients with use of emollients, along with cleaning of the washing machine by running an empty wash, and repeated washing or sometimes disposal of BAK-contaminated clothing. CONCLUSION: This large case series highlighted the characteristic clinical presentation of HKFE in the setting of BAK used in laundry sanitizer, demonstrating a potential causal link. Further studies are required to evaluate the role of the skin microbiome.

Solution using Stomahesive® wafers for allergic contact dermatitis caused by isobornyl acrylate in glucose monitoring sensors.

Isobornyl acrylate (IBOA) has recently caused a number of cases of allergic contact dermatitis (ACD) from its use in medical devices. We would like to enhance the awareness of this issue with the reporting of three Australian cases, involving two adults and a child. We also report a successful solution by using hydrocolloid wafer (Stomahesive®) as a barrier. As IBOA is not usually found on baseline patch test series and does not cross-react with other acrylic monomers, ACD to IBOA may be missed by clinicians.

Contact dermatitis.

Contact dermatitis (CD) is among the most common inflammatory dermatological conditions and includes allergic CD, photoallergic CD, irritant CD, photoirritant CD (also called phototoxic CD) and protein CD. Occupational CD can be of any type and is the most prevalent occupational skin disease. Each CD type is characterized by different immunological mechanisms and/or requisite exposures. Clinical manifestations of CD vary widely and multiple subtypes may occur simultaneously. The diagnosis relies on clinical presentation, thorough exposure assessment and evaluation with techniques such as patch testing and skin-prick testing. Management is based on patient education, avoidance strategies of specific substances, and topical treatments; in severe or recalcitrant cases, which can negatively affect the quality of life of patients, systemic medications may be needed.

Allergic contact dermatitis to phenol-formaldehyde resin at a single tertiary dermatology centre.

BACKGROUND: Phenol-formaldehyde resin 2 (PFR2) has been shown to be a useful marker of contact allergy (CA) to various phenol-formaldehyde resins. These compounds are used in several industries as solids, powders, or semisolid resins, and are known to be sensitizing agents. OBJECTIVES: The aims were to investigate contact allergy to PFR2 in a single tertiary dermatology centre, to examine associated simultaneous allergic reactions, and to identify cases of allergic contact dermatitis (ACD) to PFR2. METHODS: A retrospective study was performed of patients patch tested to PFR2 between 1 January 2003 and 17 June 2020. RESULTS: In all, 337 of 7922 patients were tested to PFR2 and 16 (4.7%) reacted. Of those 16 individuals, six (37.5%) had a relevant reaction (1.8% of total). Simultaneous allergic reactions were noted to colophonium in eight (50.0%) patients, Myroxylon pereirae in five (31.3%), and fragrance mix I (FMI) of three cases (18.8%). CONCLUSION: Contact allergy to PFR2, even in a selected population of patients, is uncommon. However, patients exposed to plastics and glues, or who work with wood products should be routinely patch tested to a plastics and glues series containing PFR2. We recommend that all centres include PFR2 in their plastics and glues series.

Allergic Contact Dermatitis to Dermabond Prineo After Elective Orthopedic Surgery.

The Dermabond Prineo skin closure system (Ethicon, Somerville, New Jersey) is a wound closure device that combines a 2-octyl cyanoacrylate liquid adhesive and a self-adhesive polyester mesh. Although cyanoacrylates traditionally have been associated with low rates of sensitization, allergic contact dermatitis (ACD) to Dermabond products is being increasingly reported after orthopedic surgery. The authors describe the first case series of ACD to Dermabond Prineo where patch testing confirmed the diagnosis in all patients. Six patients who had suspected Dermabond Prineo ACD after lower limb orthopedic surgery were assessed. Of these patients, 5 had itching within 4 days of surgery and rash within 5 days. All 5 of these patients reported previous exposure to Dermabond products. All patients had removal of the adhesive and mesh earlier than planned and were treated with corticosteroids. In addition, 4 patients received systemic antibiotics; however, only 1 had a microbiologically confirmed superficial skin infection. In all patients, the dermatitis resolved within 2 weeks of dressing removal, with no adverse effect on the orthopedic outcome. Patch testing showed positive reactions to Dermabond Prineo glue for all patients. Orthopedic surgeons should be aware of the potential for ACD to Dermabond Prineo, especially among patients with previous exposure to Dermabond products. The authors discuss the risk factors for ACD to Dermabond Prineo in the orthopedic cohort and provide recommendations for prevention and management. [Orthopedics. 2020;43(6):e515-e522.].

A cross-sectional study of dermatological conditions in rural and urban Timor-Leste.

BACKGROUND: There is limited information about the type of skin disease in Timor-Leste. In order to determine the type and magnitude of skin disease in Timor-Leste, we conducted a cross-sectional point prevalence study of 271 patients from rural and urban Timor-Leste. The aim of the study was to estimate the magnitude and burden of dermatological disease. METHODS: Two Australian-trained dermatologists conducted clinics in the city of Dili (urban) and village of Manusae (rural) in Timor-Leste between the period of June and July 2016. They independently recorded all patient presentations and diagnoses. RESULTS: A total of 271 patients were reviewed over two months, of whom 37% were seen in an urban setting and 63% in a rural setting. Scabies accounted for 96% of all presentations in the rural setting, which was significantly higher than its presentation in the urban setting (8%), P < 0.001. Scabies also accounted for the majority of presentations in the paediatric population aged 10 years or younger. Fungal and bacterial skin and soft tissue infections were both more common in urban areas (P < 0.001). CONCLUSIONS: Scabies infection remains the most prevalent dermatological condition encountered in the Timor-Leste rural population and has hopefully been addressed by a recent mass drug administration. It is important to raise awareness of the systemic problems that can arise from untreated skin infections.

Occupational contact dermatitis caused by opioids: A case series.

BACKGROUND: Opioid-manufacturing facility workers are at risk of developing occupational contact dermatitis. OBJECTIVES: To describe the causes of occupational allergic contact dermatitis caused by opioids in an opioid-manufacturing facility. MATERIALS AND METHODS: A retrospective review was performed of patients assessed at the Occupational Dermatology Clinic in Melbourne, Australia from 2004 to 2017. RESULTS: Fifteen workers from an opioid-manufacturing facility were assessed in our clinic over a period of 14 years. Of these, 11 individuals were diagnosed with occupational allergic contact dermatitis caused by opioids, with seven reacting to thebaine, five to morphine, four to norhydroxymorphinone, two to codeine, and two to oripavine. Two people were suspected of having immediate hypersensitivity reactions to opioids, including one who also had allergic contact dermatitis. Two patients were diagnosed with urticaria, aggravated at work. One patient was diagnosed with a non-occupational rash. CONCLUSIONS: We report a case series of workers with allergic contact dermatitis caused by opioids in a manufacturing facility. With greater awareness, including implementation of an educational programme and improved skin protection, the number of cases declined over time. Interestingly, norhydroxymorphinone had not been reported as an allergen before. Further testing is required to establish optimal patch test concentrations of all opiates.

Contact allergy and allergic contact dermatitis caused by lavender: A retrospective study from an Australian clinic.

BACKGROUND: Lavender is commonly used in aromatherapy and in a broad range of personal and household products. It has been identified as a contact sensitizer, and has been reported to cause allergic contact dermatitis (ACD). OBJECTIVES: To report our experience with contact allergy and ACD caused by lavender, and to raise awareness of lavender as a potential contact allergen. METHOD: A retrospective database review was performed of patients attending patch testing clinics at the Skin and Cancer Foundation, Victoria, Australia, from January 1, 1993 to December 31, 2017. RESULTS: Among the 2178 patients patch tested with lavender over this period, a total of 58 positive reactions were recorded in 49 individuals, giving a positive patch test prevalence for patients tested with lavender of 2.2%. Twenty-seven patients were diagnosed with ACD. The most common sources of exposure to lavender were personal care products and essential oils. Of the patients with ACD, 74% were tested with lavender absolute, with positive results in 90% of cases. CONCLUSION: Lavender is an uncommon cause of ACD but is important to consider, given the potential for exposure through the use of personal care items and essential oils.

Severe cutaneous eruptions following the topical use of preparations containing bufexamac: Is it time to reconsider its registration in Australia?

Despite being a well-recognised cause of allergic contact dermatitis with an embargo in many countries around the world, bufexamac is available over the counter in topical preparations in Australia. We present a series of patients who developed severe cutaneous eruptions after the topical application of bufexamac containing preparations to highlight the potential risks of this medication, as well as advocate for the reconsideration of its registration by the Therapeutic Goods Administration in Australia.

An update of the pathogenesis of frontal fibrosing alopecia: What does the current evidence tell us?

Frontal fibrosing alopecia (FFA) is a primary patterned cicatricial alopecia with a complicated pathogenesis yet to be fully understood. FFA appears to be increasing in incidence worldwide, especially in the last decade. In order to consider current treatment options, we reviewed current evidence for its pathogenesis comprising immune-mediated, genetic, hormonal and environmental factors. Th1-mediated inflammation with collapse of hair follicle immune privilege and bulge epithelial stem cell destruction, peroxisome proliferator-activated receptor gamma (PPAR-γ) depletion and epithelial-mesenchymal transition are key events leading to permanent hair follicle destruction in FFA. Although the vast majority of cases are sporadic, familial reports of FFA implicate genetic or epigenetic mechanisms in its pathogenesis. The frequent onset of FFA in post-menopausal women, similar patterning and co-existence with female pattern hair loss, together with a reportedly good response to 5α-reductase inhibitors suggest a role for sex steroid hormones. The reported increasing incidence invites speculation for, yet unproven, environmental triggers such as sun exposure and topical allergens. More robust research into this unique entity is required to help understand the complexity of the pathogenesis of FFA in order to find satisfactory therapeutic targets for this often distressing condition.

Does clinical testing support the current guidance definition of prolonged contact for nickel allergy?

BACKGROUND: The European Chemical Agency (ECHA) definition of prolonged contact was introduced in 2014 and has not been evaluated clinically. OBJECTIVES: To assess whether nickel-sensitized individuals react on patch testing with high nickel-releasing metal discs for short and repetitive periods. MATERIALS AND METHODS: We patch tested 45 nickel-sensitized individuals double-blind with 2 different types of high nickel-releasing discs for 10, 30 and 60 minutes on 3 occasions over a period of 2 weeks, and for 1 longer period. Discs were tested for nickel release. RESULTS: Nickel release from both discs significantly exceeded the 0.5 µg Ni/cm2 /week limit of the EU REACH nickel restriction. However, only 1 individual tested had a largely dose-dependent allergic reaction. CONCLUSIONS: The majority of nickel-allergic subjects did not react to nickel discs after 2 hours or after repetitive exposures of up to 30 minutes on 3 occasions over a period of 2 weeks. The length of time needed to cause nickel allergic contact dermatitis in most nickel-allergic individuals is longer than the ECHA guidance definition. Longer test times are needed to define the time required to cause dermatitis in most nickel-allergic individuals. As a limitation, the test conditions did not adequately assess real-life factors such as friction, which is relevant for some uses of nickel.

Pseudoepitheliomatous hyperplasia secondary to allergic contact dermatitis to Grevillea†Robyn Gordon.

We report a case of pseudoepitheliomatous hyperplasia (PEH) in a 55-year-old woman following allergic contact dermatitis (ACD) to Grevillea Robyn Gordon. We believe this to be the first reported case of PEH secondary to ACD, and postulate that this was an exaggerated response to severe ACD as a result of a lack of topical treatment.