Patch test results with fragrance markers of the baseline series - analysis of the European Surveillance System on Contact Allergies (ESSCA) network 2009-2012.

BACKGROUND: Contact allergy to fragrances is common, and impairs quality of life, particularly in young women. OBJECTIVE: To provide current results on the prevalences of sensitization to fragrance allergens used as markers in the baseline series of most European countries. METHODS: Data of patients consecutively patch tested between 2009 and 2012 in 12 European countries with fragrance allergens contained in the baseline series were collected by the European Surveillance System on Contact Allergies network and descriptively analysed. Four departments used the TRUE Test(®) system. RESULTS: The 'basic markers' were tested on 51 477 [fragrance mix II (FM II)] to 57 123 [Myroxylon pereirae, balsam of Peru] patients, and yielded positive reactions as follows: fragrance mix I 6.9%, Myroxylon pereirae 5.4%, FM II 3.8%, colophonium 2.6%, and hydroxyisohexyl 3-cyclohexene carboxaldehyde 1.7%, with some regional differences. Prevalences with TRUE Test(®) allergens were lower. Additional fragrances were tested on 3643 (trimethylbenzenepropanol) to 14 071 (oil of turpentine) patients, and yielded between 2.6% (Cananga odorata) and 0.7% (trimethylbenzenepropanol) positive reactions. CONCLUSIONS: Contact allergy to fragrances is common throughout Europe, with regional variation probably being explained by patch test technique, and differences in exposure and referral patterns. The current basic markers of fragrance sensitivity in the baseline series should be supplemented with additional fragrance allergens.

Monitoring contact sensitization to p-phenylenediamine (PPD) by patch testing with PPD 0.3% in petrolatum.

BACKGROUND: Being a contact allergen of general relevance, p-phenylenediamine (PPD) is patch tested in the baseline series. However, PPD 1% in petrolatum may actively sensitize. Patch testing with PPD at 0.35% pet. proved to be safe, as far as active sensitization is concerned. OBJECTIVES: To determine whether PPD 0.3% pet. reliably detects PPD sensitization. METHODS: Patch testing with PPD 0.3% pet. and 1% pet. synchronously was performed in consecutive patients in a multicentre study within the Information Network of Departments of Dermatology. RESULTS: Altogether, 2042 patients were patch tested. PPD 1% pet. yielded 6.0% positive reactions (n = 123), and PPD 0.3% pet. yielded 4.7% (n = 95). The synchronous reproducibility of PPD reactions was similar as known from parallel patch tests with identical PPD concentrations. The diagnostic properties of PPD 0.3% pet. expressed as reaction index and positivity ratio were good. Of the 123 patients reacting to PPD 1% pet., 32 (26%) had no positive reaction to PPD 0.3% pet. In 22 of these 32 patients (69%), no clinical relevance could be found. CONCLUSIONS: As patch testing with PPD 0.3% pet. is reliable according to our results, we recommend replacing PPD 1% pet. in the baseline series with PPD 0.3% pet.

Current patch test results with the European baseline series and extensions to it from the 'European Surveillance System on Contact Allergy' network, 2007-2008.

BACKGROUND: The pattern of contact sensitization to the supposedly most important allergens assembled in the baseline series differs between countries, presumably at least partly because of exposure differences. Objectives. To describe the prevalence of contact sensitization to allergens tested in consecutive patients in the years 2007 and 2008, and to discuss possible differences. METHODS: Data from the 39 departments in 11 European countries comprising the European Surveillance System on Contact Allergy network (www.essca-dc.org) in this period have been pooled and analysed according to common standards. RESULTS: Patch test results with the European baseline series, and country-specific or department-specific additions to it, obtained in 25 181 patients, showed marked international variation. Metals and fragrances are still the most frequent allergens across Europe. Some allergens tested nationally may be useful future additions to the European baseline series, for example methylisothiazolinone, whereas a few long-term components of the European baseline series, namely primin and clioquinol, no longer warrant routine testing. CONCLUSIONS: The present analysis points to 'excess' prevalences of specific contact sensitization in some countries, although interpretation must be cautious if only few, and possibly specialized, centres are representing one country. A comparison as presented may help to target in-depth research into possible causes of 'excess' exposure, and/or consideration of methodological issues, including modifications to the baseline series.

Patch testing with hydroxyethyl-p-phenylenediamine sulfate - cross-reactivity with p-phenylenediamine.

BACKGROUND: Adverse reactions to permanent hair dyes are frequent, and primarily result from sensitization to p-phenylenediamine (PPD). OBJECTIVES: To investigate the degree of cross-reactivity to a chemically similar dye, hydroxyethyl-p-phenylenediamine sulfate (HPPS), and whether this might be a dyeing alternative for patients who are sensitive to PPD. METHOD: HPPS was patch tested in two concentrations in a total of 216 patients suspected of having contact dermatitis caused by hair dyes and/or hair cosmetics. A regular use test with a hair dye containing HPPS was suggested to every patient who had had an adverse reaction to a PPD hair dye in the past. RESULTS: Forty of 216 (19.9%) patients reacted to 1% PPD, whereas only 2/216 (0.9%) showed a positive reaction to 1% HPPS. Reactivity to 2% HPPS was only slightly higher (5/216, 2.3%). On the basis of the 43 PPD-positive patients, the reactivity to 2% HPPS amounted to 12%; the corresponding figure for toluene-2,5-diamine was 15% (5/33). In a use test on two PPD-positive patients with a hair dye containing HPPS, no adverse reaction was seen, even after several years of regular dyeing. CONCLUSIONS. HPPS may be an alternative hair dye for individuals not tolerating PPD-containing dyes. However, cross-reactivity with PPD and other aromatic amines may occur. HPPS is also a known sensitizer, and the risk of de novo sensitization can only be assessed by a controlled study on a large panel and under regular use conditions.

The 'overall yield' with the baseline series - a useful addition to the array of MOAHLFA factors describing departmental characteristics of patch tested patients.

BACKGROUND: The proportion of patients with a positive patch test reaction to at least one allergen from the baseline series differs between departments. OBJECTIVES: To further define the above mentioned proportion, termed the 'P' measure, to examine factors associated with this measure, to describe its variation over time and between centres, and to discuss possible uses. PATIENTS AND METHODS: Eighteen departments have been 'long-term' participants in the Information Network of Departments of Dermatology (IVDK; www.ivdk.org), that is, since 1995 (1997 in two cases). In these departments, 80 919 consultations for patch testing with the baseline series, in the composition of the series valid at that time, were documented until December 2009. Bivariate and multifactorial analyses addressed factors associated with being patch test-positive to at least one baseline series allergen. RESULTS: Of the study population, 46.5% had at least one positive test reaction, with considerable variation being seen between centres and a general decline during the study period. Among other factors, female sex, occupational causation and a high suspicion of allergic contact dermatitis were significantly associated with having at least one positive patch test reaction to the baseline series. CONCLUSIONS: The 'P' measure should prove useful as another perspective on departmental characteristics, and should be reported along with established variables (MOAHLFA index).

A comparison of mycophenolate mofetil with ciclosporine for the treatment of chronic plaque-type psoriasis.

AIMS: To compare the efficacy of ciclosporine (CsA) versus mycophenolate mofetil (MMF) in psoriasis, a randomized trial was conducted. METHODS: A prospective multicenter randomized open-label clinical trial was performed to compare two parallel groups of patients with chronic plaque psoriasis undergoing different treatments. Therefore, a total of 54 patients with psoriasis were randomly assigned to treatment with either CsA (2.5 mg/kg body weight) or MMF (2 g daily) for 12 weeks, and the drug doses were adjusted according to response. The psoriasis area and severity index (PASI) was used to assess the clinical severity of psoriasis. The primary outcome of this trial was the time to disease relapse. Safety, PASI scores and psoriasis disability index (PDI) were assessed as secondary outcome. RESULTS: There was no difference in time to disease relapse between the two groups. After 12 weeks of treatment, the mean PASI score (+/-SD) decreased from 24.6 +/- 11.1 to 6.6 +/- 7.3 in the CsA group (n = 27) and from 22.4 +/- 9.2 to 10.6 +/- 6.7 in the MMF group (n = 27; p = 0.02). The side effects, time to remission and PDI were similar in both groups. CONCLUSIONS: After 12 weeks, CsA demonstrated a significantly superior efficacy in psoriasis compared to MMF.

Quantitative patch and repeated open application testing in hydroxyisohexyl 3-cyclohexene carboxaldehyde sensitive-patients.

OBJECTIVE: To identify the concentration of the fragrance compound hydroxyisohexyl 3-cyclohexene carboxaldehyde (INCI) (HICC) that is sufficiently low not to cause an allergic reaction in patients with proven sensitization. METHODS: Repeated open application testing (ROAT) in 64 subjects with 2 preparations (perfume and cream) in different concentration (0.005-2.5%). Confirmatory patch testing with four preparations in two different concentrations (2.5% and 5%). RESULTS: The concentrations of HICC being tolerated by 90% of those sensitized to HICC are estimated as <88.2 ppm (cream) and <270 ppm (perfume) equivalent to 1.2 microg/cm(2) (perfume) and 4.9 microg/cm(2) (cream). Patch test preparations differed with regard to sensitivity (88.5-98.1%) and specificity (37.5-87.5%) against the ROAT result as external criterion. ROAT concentrations and the reaction strength in patch testing were inversely correlated (Kendall's tau-b: 0.69), both indicating the existence of different degrees of susceptibility. CONCLUSION: To protect 90% (50%) of people sensitized, the use concentration should be in the range of 0.009-0.027% (0.18-0.34%), depending on the product type. Taking into account these results, excessive concentrations should be avoided, as this would continue to sensitize people. Close monitoring is indispensable to prove the efficacy of any recommendations aiming to prevent induction.

Chromated metal products may be hazardous to patients with chromate allergy.

BACKGROUND: Hidden allergen exposure may contribute to persistence and relapse of chromate dermatitis. According to case reports, chromated metal products, such as screws, fittings, etc., may be relevant allergen sources for patients sensitized to chromate. OBJECTIVES: To examine concomitant patch test reactivity to potassium dichromate 0.5% petrolatum (pet.) and three different types of chromated metal rings. PATIENTS/METHODS: Patients with proven or suspected chromate allergy were patch tested with potassium dichromate 0.5% pet. and three different types of chromated metal rings (yellow, olive, and black). Hexavalent chromium Cr(VI) release from the patch tested rings was chemically analysed. RESULTS: Ninety-five patients were tested: 49/95 (52%) reacted to potassium dichromate and 25/95 (26%) reacted to black chromated rings. Reactions to chromated rings exclusively occurred in patients reacting to potassium dichromate. Of 20 patients with a strong reaction to potassium dichromate, 14 reacted to black chromated rings. These were shown to have a high Cr(VI) release. Only two patients reacted to the other chromated rings, which had a very low Cr(VI) release. CONCLUSIONS: Handling chromated metal products must be regarded a hazard to chromate-sensitive patients, in particular those with a strong sensitization.

The European baseline series in 10 European Countries, 2005/2006--results of the European Surveillance System on Contact Allergies (ESSCA).

BACKGROUND: Continual surveillance based on patch test results has proved useful for the identification of contact allergy. OBJECTIVES: To provide a current view on the spectrum of contact allergy to important sensitizers across Europe. PATIENTS/METHODS: Clinical and patch test data of 19 793 patients patch tested in 2005/2006 in the 31 participating departments from 10 European countries (the European Surveillance System on Contact Allergies' (ESSCA) www.essca-dc.org) were descriptively analysed, aggregated to four European regions. RESULTS: Nickel sulfate remains the most common allergen with standardized prevalences ranging from 19.7% (central Europe) to 24.4% (southern Europe). While a number of allergens shows limited variation across the four regions, such as Myroxylon pereirae (5.3-6.8%), cobalt chloride (6.2-8.8%) or thiuram mix (1.7-2.4%), the differences observed with other allergens may hint on underlying differences in exposures, for example: dichromate 2.4% in the UK (west) versus 4.5-5.9% in the remaining EU regions, methylchloroisothiazolinone/methylisothiazolinone 4.1% in the South versus 2.1-2.7% in the remaining regions. CONCLUSIONS: Notwithstanding residual methodological variation (affecting at least some 'difficult' allergens) tackled by ongoing efforts for standardization, a comparative analysis as presented provides (i) a broad overview on contact allergy frequencies and (ii) interesting starting points for further, in-depth investigation.

Annular lichenoid dermatitis of youth--a further case in a 12-year-old girl.

Annular lichenoid dermatitis of youth was first described by Annessi et al. in 2003. Clinical criteria are persistent erythematous macules and annular lesions with a red-brown edge and a central hypopigmentation usually found on the flanks and groins of children and adolescents. Histologically, the disease is characterized by a lichenoid interface dermatitis with necrotic keratinocytes at the tip of the rete ridges. In our case a 12-year old girl developed annular red-brown macules with papules at the borders in an inframammary location. The histology of the lesion's border showed a lichenoid lymphocytic infiltrate with apoptotic keratinocytes at the tip of rete ridges. The lesions cleared with 0.03% tacrolimus ointment. Annular lichenoid dermatitis of youth is probably a new entity in the group of lichenoid dermatoses.

Late onset of a facial variant of steatocystoma multiplex - calretinin as a specific marker of the follicular companion cell layer.

Steatocystoma multiplex is a rare,almost exclusively autosomal dominant disease of the sebaceous glands. The sites of predilection are the sternal region, upper back, axillae and proximal parts of the extremities. A 78-year-old woman developed multiple yellowish nodules only on the face over a few months. Histology revealed large cysts with a thin wall and connection to sebaceous glands. Immunohistochemical analysis showed the inner epithelial layer of the cysts was positive with calretinin.With curettage and CO2 laser therapy, a good cosmetic result was achieved.This is the first case report in the German literature of a rare sporadic form of steatocystoma multiplex with late onset and exclusive localization in the face.

Clinical update on contact allergy.

PURPOSE OF REVIEW: The aim of this article is to review recent findings in contact allergy, regarding clinical research. RECENT FINDINGS: The biocide methyldibromo glutaronitrile was identified to be an important sensitizer. Subsequently, it was banned from leave-on cosmetics in the European Union. Another group of important allergens that have been studied extensively included the fragrances oak moss absolute, isoeugenol, hydroxyisohexyl 3-cyclohexene carboxaldehyde and farnesol. A new fragrance mix II has been developed for standard testing, which includes the two latter compounds. Dose response studies have demonstrated broad individual variation of elicitation thresholds, dependent on the allergen concentration during induction, and other factors. Some unsuspected routes of exposure to allergens include oral, inhalational, connubial or airborne contact. Experimental studies provide a classification of newly introduced chemicals; increasingly, the local lymph node assay is supplementing and potentially replacing the guinea pig maximization test. Recent advances in occupational contact allergy include, for example, some attempts to improve diagnostics for epoxy resin and other plastic, glue, and cutting fluid components. SUMMARY: Constant awareness for new allergens, confirmed by critical evaluation, standardization of patch test materials, and the identification of temporal patterns and subgroups at risk will improve both the diagnosis and prevention of allergic contact dermatitis.

The "strip" patch test: results of a multicentre study towards a standardization.

BACKGROUND: The "strip" patch test (SPT) is a variant of patch testing which is used for substances with a poor percutaneous penetration. Penetration of the substances is enhanced by repeated applications of adhesive tape prior to their application to the skin. However, no guidelines exist for standardized performance of the SPT. OBJECTIVES: The aim of this multicentre study was to obtain a first practical approach towards a standardized SPT procedure. METHODS: Intact noninflamed skin of the upper back of 83 healthy volunteers was tape-stripped. For sequential strips, a 25-mm diameter 3M Blenderm surgical tape was vertically applied and gently pressed downward using the fingertips for about 2 s. The tape was removed in one quick movement at an angle of 45 degrees in the direction of adherence. Each strip was performed with a new piece of tape on exactly the same skin area. RESULTS. In each subject, we first determined the number of strips (A) until the skin surface started to glisten and calculated the median number of strips (A) in the sample (A=26 strips). We then ascertained the median number of strips (a) in the sample that was necessary to achieve a statistically significant and twofold increase in TEWL (a=11 strips), revealing a "critical" stratum corneum strip depth. The unknown number of strips (a) for each subject was finally calculated from the formula a/A=a/A, i.e. the individual number of strips (A) until the skin surface started to glisten was multiplied by a derived tape-specific correction factor (cf=a/A=11/26=0.4). The increase in percutaneous penetration in strip patch testing by performing "a" strips versus conventional patch testing was shown by scoring of clinical and subjective SLS irritant reactions. CONCLUSIONS: The present multicentre study outlines an experimentally derived approach for a uniform SPT procedure, which does not require the use of complex technical equipment. This first approach now requires validation by a study involving the application of allergens to obtain evidence of enhancement in the sensitivity of patch testing.

Sensitization to 26 fragrances to be labelled according to current European regulation. Results of the IVDK and review of the literature.

To study the frequency of sensitization to 26 fragrances to be labelled according to current European regulation. During 4 periods of 6 months, from 1 January 2003 to 31 December 2004, 26 fragrances were patch tested additionally to the standard series in a total of 21 325 patients; the number of patients tested with each of the fragrances ranged from 1658 to 4238. Hydroxymethylpentylcyclohexene carboxaldehyde (HMPCC) was tested throughout all periods. The following frequencies of sensitization (rates in %, standardized for sex and age) were observed: tree moss (2.4%), HMPCC (2.3), oak moss (2.0), hydroxycitronellal (1.3), isoeugenol (1.1), cinnamic aldehyde (1.0), farnesol (0.9), cinnamic alcohol (0.6), citral (0.6), citronellol (0.5), geraniol (0.4), eugenol (0.4), coumarin (0.4), lilial (0.3), amyl-cinnamic alcohol (0.3), benzyl cinnamate (0.3), benzyl alcohol (0.3), linalool (0.2), methylheptin carbonate (0.2), amyl-cinnamic aldehyde (0.1), hexyl-cinnamic aldehyde (0.1), limonene (0.1), benzyl salicylate (0.1), gamma-methylionon (0.1), benzyl benzoate (0.0), anisyl alcohol (0.0). 1) Substances with higher sensitization frequencies were characterized by a considerable number of '++/+++' reactions. 2) Substances with low sensitization frequencies were characterized by a high number of doubtful/irritant and a low number of stronger (++/+++) reactions. 3) There are obviously fragrances among the 26 which are, with regard to contact allergy, of great, others of minor, and some of no importance at all.