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.

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.

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.

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.

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.

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.

Occupational skin disease among Australian healthcare workers: a retrospective analysis from an occupational dermatology clinic, 1993-2014.

BACKGROUND: Healthcare workers (HCWs) are at risk of developing occupational skin disease (OSD). OBJECTIVES: To ascertain the causes of OSD in Australian HCWs in a tertiary referral clinic. METHODS: A retrospective review was performed of patients assessed at the Occupational Dermatology Clinic in Melbourne from 1993 to 2014. RESULTS: Of 685 HCWs assessed in the clinic over a period of 22 years, 555 (81.0%) were diagnosed with OSD. The most common diagnosis was irritant contact dermatitis (ICD) (79.1%), followed by allergic contact dermatitis (ACD) (49.7%). Natural rubber latex allergy was also relatively frequent (13.0%). The major substances causing ACD were rubber glove chemicals (thiuram mix and tetraethylthiuram disulfide), preservatives (formaldehyde, formaldehyde releasers, and isothiazolinones), excipients in hand cleansers, which are hard-to-avoid weak allergens, and antiseptics. ACD caused by commercial hand cleansers occurred more frequently than ACD caused by alcohol-based hand rubs (ABHRs). Occupational ICD was mostly caused by water/wet work and hand cleansers, and environmental irritants such as heat and sweating. CONCLUSIONS: Understanding the causes of OSD in HCWs is important in order to develop strategies for prevention. We suggest that skin care advice should be incorporated into hand hygiene education. The use of ABHRs should be encouraged, weak allergens in skin cleansers should be substituted, and accelerator-free gloves should be recommended for HCWs with OSD.

Patch testing in Australia: Is it adequate?

BACKGROUND/OBJECTIVES: Patch testing (PT) is essential for making the diagnosis of allergic contact dermatitis (ACD). However, the extent of PT undertaken by Australian dermatologists is unknown. The objectives of this study were to determine the rate and type of PT in Australia, the perceived obstacles to PT, and to explore the exposure to PT in dermatology training. METHODS: Data were collected on private PT (analysing Medicare item numbers) and public hospital-based PT (estimated via verbal reports). An online survey on PT was sent to Fellows of the Australasian College of Dermatologists. RESULTS: It was found that total PT numbers, combining Medicare item number and public hospital data, were below the suggested optimum in all states and in Australia overall. Of the 173 respondents to the survey, 61% reported they patch tested and 78% reported they referred for PT. TrueTest was the most commonly used PT system, although it is known to be inadequate. Dermatologists who PT as registrars were significantly more likely to PT as consultants (P value = 0.0029). Cost, expertise required and staffing were considered major obstacles to performing PT. Accessibility and cost to the patient were common obstacles to referral. CONCLUSIONS: The combination of suboptimal PT rates and inadequate PT means that patients are missing out on being diagnosed with ACD in Australia. Increasing the exposure of registrars to PT, supporting specialised centres, the development of the Australian Baseline Series and the Contact Allergen Bank will, it is hoped, improve the rates of comprehensive PT in Australia.

Allergic contact dermatitis to substitute hair dyes in a patient allergic to para-phenylenediamine: Pure henna, black tea and indigo powder.

We report a case of a 50-year-old lady with allergic contact dermatitis to para-phenylenediamine, who in her quest to find a substitute hair dye, subsequently reacted to a number of plant-based hair dyes, including pure henna, black tea and indigo powder respectively. While these substances all contain tannins, testing to possible constituents tannic acid and gallic acid was negative.

Occupational skin disease in Victoria, Australia.

OBJECTIVES: To describe the characteristics of patients with occupational skin disease (OSD) in a tertiary referral clinic in Victoria, Australia. METHODS: A retrospective review was conducted of records from patients seen at the Occupational Dermatology Clinic in Melbourne, Australia between 1 January 1993 and 31 December 2010. RESULTS: Of the 2894 people assessed in the clinic during the 18-year period, 44% were women and 56% were men. In all, 2177 (75%) were diagnosed with occupational skin disease (OSD). Of the patients with a work-related skin condition, 45% (n = 979) were considered to be atopic. The most common diagnosis in those with OSD was irritant contact dermatitis (ICD) (44%), followed by allergic contact dermatitis (33%) and endogenous eczema (11%). Women were significantly more likely to have soaps and detergents (P < 0.001) and water/wet work (P < 0.001) as causes of their ICD than men. Men were significantly more likely to have oils and coolants (P < 0.001) and solvent exposures (P < 0.001) as causes of their ICD. Occupational groups with the highest incidence of OSD were the hair and beauty professions (70 per 100 000), followed by machine and plant operators (38 per 100 000) and health-care workers (21 per 100 000). CONCLUSION: We confirm the importance of occupational contact dermatitis as the most common cause of OSD, with ICD being the most common diagnosis. There are differences in the causes of ICD between our group of male and female workers. For the first time in Australia, rates of OSD in certain industries have been calculated.

Use of antiseptic hand rubs in the health and community services industry: an Australian population-based survey.

BACKGROUND: The use of antiseptic hand rubs (AHRs), rather than washing with soap and water, is considered to be the gold standard for reducing the frequency of nosocomial infections, as well as being less damaging to the hands than washing with soap and water, but little is known at a population level about usage patterns for AHRs. OBJECTIVES: To describe AHR use patterns among workers in the health and community services industry in Australia. METHODS: Using data from a population-based survey of Australian workers, we focused on health and community services workers' exposure to chemicals at work, including the use of AHRs. Data regarding the frequency of hand-washing were also collected. RESULTS: Nine hundred and fifty-six health and community service workers participated in the Australian National Hazard Exposure Worker Surveillance survey. Of these, 11% reported using AHRs, and 31% reported hand-washing >20 times per shift. According to an adjusted logistic regression model, professional workers [adjusted odds ratio (aOR) 2.29, 95% confidence interval (CI): 1.40-3.72] and frequent hand washers (aOR 3.08, 95%CI: 1.92-4.93) were more likely to use AHRs. CONCLUSIONS: AHR use by health and community service workers was generally lower than expected. AHR use was most likely to be reported by professionals and frequent hand washers, suggesting that AHRs are used as an adjunct to conventional hand-washing.

Tobacco smoking and hand eczema - is there an association?

BACKGROUND: Numerous risk factors have been suggested for hand eczema. This systematic review evaluates the association between tobacco smoking and hand eczema. OBJECTIVE: To review the literature systematically on the association between smoking and hand eczema. METHODS: The PubMed and EMBASE databases were searched up to 27 January 2015 for articles on the association between tobacco smoking and hand eczema, including human studies in English and German only. Experimental studies, studies on tobacco allergy, case reports, reviews and studies on second-hand smoking were excluded. RESULTS: Twenty articles were included. Among studies in occupational settings, three of seven found a statistically significant positive association between tobacco smoking and hand eczema prevalence rate, as did four of eight population-based studies. The association was stronger for studies in occupational settings than for population-based studies. No studies reported tobacco to be a clear protective factor for hand eczema. Two of five studies regarding severity found a positive association between smoking and hand eczema severity. CONCLUSION: Overall, the data indicate that smoking may cause an increased frequency of hand eczema, particularly in high-risk occupations. However, data from studies controlling for other risk factors are conflicting, and few prospective studies are available. Studies controlling for other risk factors are needed, and information regarding the diagnosis of subclasses of hand eczema, as well as severity, may be important.