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Contact Dermatitis

Top 10 Scientific Articles in the field of contact dermatitis published in 2017.

The current spectrum of contact sensitization in patients with chronic leg ulcers or stasis dermatitis - new data from the Information Network of Departments of Dermatology (IVDK).
Erfurt-Berge C, Geier J, Mahler V.
Contact Dermatitis. 2017; 77:3. doi: 10.1111/cod.12763. Epub 2017 Feb 14.
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Reviewer’s Comments: The decrease in the number of patients tested and a lower number of positivities found may be due to the fact that the patch tests do not detect the allergenic substances in the new materials used for the treatment of leg ulcers or stasis dermatitis, or to a greater awareness among doctors who treat these injuries to avoid substances known as sensitizers. It is very important in these patients to test their own products to arrive at an accurate diagnosis.

Background: Patients with lower leg dermatitis, chronic venous insufficiency or chronic leg ulcers have a high prevalence of contact sensitization.
Objectives: To identify the current spectrum of contact allergens in these patients.
Patients and Methods: Data of the Information Network of Departments of Dermatology on 5264 patients with the above diagnoses from the years 2003 to 2014 (study group) were compared with data on 4881 corresponding patients from 1994 to 2003 (historical control group) and with a current control group without these diagnoses (n = 55 510).
Results: Allergic contact dermatitis was diagnosed less frequently in the study group than in the historical control group (25.9% versus 16.9%; p < 0.001), and contact sensitization to most allergens had declined. The allergen spectrum, however, was largely unchanged. Important allergens are Myroxylon pereirae (balsam of Peru) (14.8% positive reactions), fragrance mix I (11.4%), lanolin alcohol (7.8%), colophonium (6.6%), neomycin sulfate (5.0%), cetearyl alcohol (4.4%), oil of turpentine (3.1%), and paraben mix (2.6%). Patch testing with additional series showed sensitization to Amerchol L-101 (9.7%), tert-butyl hydroquinone (8.7%), framycetin sulfate (5.0%), and gentamicin sulfate (3.1%).
Conclusions: Topical preparations for treating the above-mentioned conditions should not contain fragrances, Myroxylon pereirae, and colophonium. The special allergen spectrum has to be considered in patch testing.


Prevalence of nickel allergy in Europe following the EU Nickel Directive - a review.
Ahlström MG, Thyssen JP, Menné T, Johansen JD.
Contact Dermatitis. 2017; 77:4. doi: 10.1111/cod.12846. Epub 2017 Jul 21.
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Reviewer’s Comments: The implementation of a European regulation since 2001 on the maximum amounts of nickel to which citizens can be exposed has meant a decrease in the prevalence of patients sensitized to nickel (more in women than in men). However, more measures should be taken in this regard since nickel remains one of the major sensitizers in patch tests. This type of legislation should also be valued by other countries since nickel sensitization is the leading cause of allergic contact dermatitis, considered a global pandemic.

Abstract: Nickel contact allergy remains a problem in EU countries, despite the EU Nickel Directive. To study the prevalence of nickel allergy in EU countries following the implementation of the EU Nickel Directive, we performed a systematic search in PubMed for studies that examined the prevalence of nickel allergy in EU countries published during 2005-2016. We identified 46 studies: 10 in the general population and 36 in patch tested dermatitis patients. A significantly lower prevalence of nickel allergy after than before the implementation of the EU NickelDirective was found in women aged 18-35 years (11.4% versus 19.8%) (p = 0.02), in female dermatitis patients aged ≤17 years (14.3% versus 29.2%) (p < 0.0001), and in dermatitis patients aged 18-30 years (women: 20.2% versus 36.6%) (p < 0.0001) (men: 4.9% versus 6.6%) (p < 0.0001). Overall, the prevalence was higher in southern than in northern EU countries, and generally remained high, affecting 8-18% of the general population. A consistent pattern of decreasing prevalence of nickel allergy in some EU countries was observed, although the prevalence among young women remains high. Steps should be taken for better prevention of nickel allergy in EU countries.


Contact Allergy Cross-reactions: Retrospective Clinical Data and Review of the Literature.
Scheman A, Hipolito R, Severson D, Youkhanis N.
Dermatitis. 2017; 28:2. doi: 10.1097/DER.0000000000000254.
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Reviewer’s Comments: The authors tell us about the phenomenon of cross-reactivity between different substances: the mechanism involved and how to differentiate this from co-reaction. Correct information on cross-reactivity is useful for the clinician. Furthermore, by providing a database of alternative products for allergic patients, such as Contact Allergy Management Program (CAMP) of the American Contact Dermatitis Society (ACDS), the clinician can help the patient prevent future reaction. In the article, cross-reactivity between different fragrances, formaldehyde and formaldehyde-releasing preservatives, PARA compounds, methacrylates, and others are reviewed.

Abstract: We discuss cross-reactions that can occur when a patient allergic to a specific allergen also reacts to a similar allergen. Currently, The American Contact Dermatitis Society Contact Allergy Management Program, which allows physicians to identify safe products for their patients, uses a 10% threshold to distinguish significant cross-reactors. New clinical data from a patch testing center along with previous data in the literature are analyzed to help determine whether current cross-reactor definitions are reasonable or should be altered.


Contact Allergy to (Ingredients of) Toothpastes.
de Groot A.
Dermatitis. 2017; 28:2. doi: 10.1097/DER.0000000000000255.
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Reviewer’s Comments: The contact allergy to toothpastes is a subject that is not sufficiently studied. The author details the different chemical substances that can be included in these pastes, usual and unusual. He also details the medical literature (clinical cases, studies with a small number of patients) that leads him to postulate that the prevalence of sensitization to these products is low. He also discusses that this may be an underestimated pathology. Finally, the author analyzes the possibilities of performing patch tests in patients with suspected sensitization.

Abstract: The literature on contact allergy to (ingredients of) toothpastes is critically reviewed. We have found 47 case reports, small case series (n = 2-5) and citations published between 1900 and 2016 describing more than 60 patients allergic to toothpastes, and in addition 3 larger case series and many descriptions of toothpaste allergy among selected groups of patients. Allergic reactions usually manifest as cheilitis with or without dermatitis around the mouth, less frequently by oral symptoms. Formerly, many reactions were caused by cinnamon derivatives; more recently, reported allergens are diverse. A semiopen test or closed patch test with the toothpaste "as is" may be performed as an initial test, but a positive reaction should always be followed by confirmatory tests. The role of contact allergy to toothpastes in patients with oral symptoms (stomatitis, glossitis, gingivitis, buccal mucositis, burning, soreness, and possibly burning mouth syndrome and recurrent aphthous ulcers) is unclear and should be further investigated.


Preventing Occupational Skin Disease: A Review of Training Programs.
Zack B, Arrandale VH, Holness DL.
Dermatitis. 2017; 28:3. doi: 10.1097/DER.0000000000000278.
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Reviewer’s Comments: The authors conduct a systematic review of different training plans carried out with workers to reduce the prevalence of occupational contact dermatitis. They include both wet workers (health workers, hairdressers, cleaning staff and food handlers), as well as manufacturing workers. It would be interesting to conduct long-term studies to assess the effectiveness of these training plans.

Abstract: Occupational contact dermatitis (OCD) is a common occupational disease that impacts a variety of worker groups. Skin protection and disease prevention training programs have shown promise for improving prevention practices and reducing the incidence of OCD. This review details the features of training programs for primary prevention of OCD and identifies gaps in the literature. Twelve studies were identified for in-depth review: many studies included wet workers employed in health care, hairdressing, cleaning, and food preparation; 1 program featured manufacturing workers. Few programs provided content on allergic contact dermatitis, and only 1 was evaluated for long-term effectiveness. Effective programs were similar in content, delivery method, and timing and were characterized by industry specificity, multimodal learning, participatory elements, skin care resource provision, repeated sessions, and management engagement. Long-term effectiveness, generalizability beyond OCD, workplace health and safety culture impact, and translation of programs in the North American context represent areas for future research.


Contact Sensitization to Allergens in Nail Cosmetics.
Chou M, Dhingra N, Strugar TL.  
Dermatitis. 2017; 28:4. doi: 10.1097/DER.0000000000000301.
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Reviewer’s Comments: There is currently an epidemic of contact dermatitis in relation to the materials used in esthetics for the nails. While this pathology has been known for many years, its expansion of use in the population has meant an increase in the prevalence of sensitization. The related symptoms affect the nails and nearby cutaneous area, but also other areas of the body (face...) in contact with the nails. There is also the possibility of airborne reactions and asthma. This type of allergic contact dermatitis affects individual users but also, very often, beauticians who work with these materials for a long time, without using correct preventive measures.

Abstract: Ingredients found in the nail cosmetic industry, including but not limited to methacrylate and acrylate monomers, formaldehyde, and toluene sulfonamide-formaldehyde resin, can incite allergic contact dermatitis. An eczematous outbreak presents on areas surrounding the nail plate and may spread through contact transfer of the allergen, commonly to the face and neck. Even components that were originally deemed nonsensitizing, such as the ubiquitous cyanoacrylate adhesive family, have been found to be allergenic. They do not, however, cross-react with methacrylates and acrylates. Alternative options for individuals with allergic contact dermatitis reactions to these ingredients can be avoidance of these procedures or use of products that are "3, 4, 5 free" in which the common allergens dibutyl phthalate, toluene, and formaldehyde are absent. In cases where strengthening of the nail is the sole purpose, nail wraps or preformed nails can be applied for non-cyanoacrylate-sensitive individuals.


Guidelines for the presentation of contact allergy case reports.
Uter W, Goossens A, Gonçalo M, Johansen JD; , on behalf of the EECDRG.
Contact Dermatitis. 2017; 76:2. doi: 10.1111/cod.12709. Epub 2016 Dec 4.
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Reviewer’s Comments: The publication of clinical cases is a very important source of information especially for new causes of contact dermatitis. This article provides, in detail, the steps in preparing a clinical case that will optimize the acceptance of the article for publication in a specialized journal.

Abstract: Case reports constitute a classic publication format that is being increasingly appreciated, for example because of its educational value. In the field of contact dermatitis research, case reports often serve as sentinel publications concerning new allergens, or new exposures to known allergens, or regarding other conditions leading to contact dermatitis. The CARE guideline published in 2013 addresses standardized and complete reporting of case reports in all fields of medicine. The present article takes up the CARE suggestions, and further specifies these in terms of application to case reports in the field of contact dermatitis. The objective of this structured guidance is to provide junior or inexperienced doctors and researchers with an annotated list, against which the fulfillment of essential or optional items of a complete, high-quality case report to be submitted to Contact Dermatitis or other journals can be checked.


Long-term reproducibility of positive patch test reactions in patients with non-immediate cutaneous adverse drug reactions to antibiotics.
Pinho A, Marta A, Coutinho I, Gonçalo M.
Contact Dermatitis. 2017; 76:4. doi: 10.1111/cod.12720. Epub 2016 Dec 2.
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Reviewer’s Comments: The authors demonstrate with the repetition of the patch tests years after their realization for the study of delayed allergic reactions to antibiotics that these tests persist positive in a large part of them and with a reaction intensity similar to the first tests performed years before. This occurs not only with penicillins but also with other different antibiotics. This study would support the non-repetition of this type of tests in the future after its realization with a positive result.

Background: As in contact allergy, T cell-mediated hypersensitivity in non-immediate (NI) cutaneous adverse drug reactions (CADRs) to antibiotics is considered to be lifelong, but, in this setting, patch tests have rarely been repeated after long time intervals.
Objective: To evaluate the long-term reproducibility of positive patch test reactions to antibiotics in patients with NI CADRs.
Methods: Fifty-six patients with NI CADRs to antibiotics who had relevant positive reactions during patch testing were invited to repeat patch tests with a similar antibiotic series 2-15 years thereafter.
Results: Twenty patients were included (9 males and 11 females; mean age 54.6 years): 18 with maculopapular exanthema, 1 with drug hypersensitivity syndrome, and 1 with acute generalized exanthematous pustulosis. Results were reproducible in 17 of 20 patients after a mean interval of 6.0 years (range 2-14.7 years). Concerning β-lactams, 7 of 8 patients remained positive for aminopenicillins, 4 of 4 for isoxazolyl penicillins, and 1 for cefoxitin. Patch test results were also reproducible for clindamycin in 5 of 7 patients, for vancomycin in 1 patient, and for spiramycin in 1 patient. Reproducibility was not affected by the time interval between tests, sex, or age at testing.
Conclusions: In the context of NI CADRs, we showed high reproducibility of positive patch test reactions to various antibiotics, even after several years.


The epidemic of methylisothiazolinone: a European prospective study.
Schwensen JF, Uter W, Bruze M, Svedman C, Goossens A, Wilkinson M, Giménez Arnau A, Gonçalo M, Andersen KE, Paulsen E, Agner T, Foti C, Aalto-Korte K, McFadden J, White I, Johansen JD; European Environmental Contact Dermatitis Research Group.   
Contact Dermatitis. 2017; 76:5. doi: 10.1111/cod.12733. Epub 2016 Dec 28.
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Reviewer’s Comments: It is the first prospective study conducted on sensitization to MI. It would show that there is a high prevalence in different European countries (8) although with important differences between them and that would be relevant in a large part of the positivities. The most frequent affected areas are hands and face, but other areas can be affected or be generalized at times.

Background: The use of methylisothiazolinone (MI) in cosmetic products has caused an unprecedented epidemic of MI contact allergy. Current data concerning exposures at a European level are required.
Objectives: To describe demographics and MI exposures for European patients with MI contact allergy.
Methods: Eleven European dermatology departments from eight European countries prospectively collected data between 1 May and 31 October 2015 among consecutive patients who had positive patch test reactions to MI (2000 ppm aq.).
A total of 6.0% (205/3434; range 2.6-13.0%) of patients had positive patch test reactions to MI. Dermatitis most frequently affected the hands (43.4%), face (32.7%), arms (14.6%), and eyelids (11.7%); 12.7% had widespread dermatitis. For 72.7% (149/205), MI contact allergy was currently relevant mainly because of exposure to cosmetic products (83.2%; 124/149). Of these 124 patients, 19.5% were exposed to leave-on and rinse-off cosmetic products, 24.8% only to leave-on cosmetic products and 38.9% only to rinse-off cosmetic products containing MI or methylchloroisothiazolinone/MI. The majority of these (79%) noted onset of their dermatitis between 2013 and 2015. Fifteen patients (7.3%) had previously experienced allergic reactions when they were in newly painted rooms.
Conclusion: Clinically relevant MI contact allergy remains prevalent across European countries, mainly because of exposure to rinse-off and leave-on cosmetic products.


Current knowledge on biomarkers for contact sensitization and allergic contact dermatitis.
Koppes SA, Engebretsen KA, Agner T, Angelova-Fischer I, Berents T, Brandner J, Brans R, Clausen ML, Hummler E, Jakasa I, Jurakić-Tončic R, John SM, Khnykin D, Molin S, Holm JO, Suomela S, Thierse HJ, Kezic S, Martin SF, Thyssen JP.
Contact Dermatitis. 2017; 77:1. doi: 10.1111/cod.12789. Epub 2017 May 12.
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Reviewer’s Comments: The authors develop in this review an exhaustive search of different biomarkers that have been used in recent years for the study of contact dermatitis. Unfortunately, none of them constitutes a specific marker of allergic contact dermatitis as they only identify the presence of inflammation. Genomics and proteomics should also be studied as biomarkers that could help to identify contact sensitization and/or contact dermatitis.

Abstract: Contact sensitization is common and affects up to 20% of the general population. The clinical manifestation of contact sensitization is allergic contact dermatitis. This is a clinical expression that is sometimes difficult to distinguish from other types of dermatitis, for example irritant and atopic dermatitis. Several studies have examined the pathogenesis and severity of allergic contact dermatitis by measuring the absence or presence of various biomarkers. In this review, we provide a non-systematic overview of biomarkers that have been studied in allergic contact dermatitis. These include genetic variations and mutations, inflammatory mediators, alarmins, proteases, immunoproteomics, lipids, natural moisturizing factors, tight junctions, and antimicrobial peptides. We conclude that, despite the enormous amount of data, convincing specific biomarkers for allergic contact dermatitis are yet to be described.

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