Prevalence and risk factors for allergic contact dermatitis to topical treatment in atopic dermatitis: a study in 641 children

Patch testing in Israeli children with suspected allergic contact dermatitis: A retrospective study and literature review

BACKGROUND/OBJECTIVES

Childhood allergic contact dermatitis is recognized as a significant clinical problem. The objective was to evaluate the rate of positive patch tests in Israeli children with clinically suspected allergic contact dermatitis, identify possible sex and age differences, compare results with those in Israeli adults, and review pediatric studies in the literature.

METHODS

The study sample included 343 children and adolescents (197 female, 146 male; 1-18 years of age, mean age 11.8 years) with clinically suspected allergic contact dermatitis who underwent patch testing with a standard pediatric series of 23 allergens at a tertiary medical center from 1999 to 2012. Data on clinical characteristics and test results were collected retrospectively from the medical files.

RESULTS

Ninety-eight subjects (28.6%) (75 girls [38.1%], 23 boys [15.8%]) had at least one positive reaction. The most frequent reactions were to nickel sulfate, followed by potassium dichromate and cobalt chloride. Nickel sulfate sensitivity was more common in girls, especially those younger than 3 years and older than 12 years. The prevalence of contact sensitization was similar in subjects with and without atopic dermatitis (50% and 51%, respectively).

CONCLUSION

Nickel is the most common allergen in Israeli children, especially girls. Patch testing should be performed in children with clinically suspected allergic contact dermatitis regardless of atopic background.

[Basis for the treatment of eczematous diseases in otorhinolaryngology]

According to Coombs and Gell, cell-mediated immune responses belong to type IV reactions and are borne mainly by T lymphocytes. The eliciting allergens are usually so-called haptens. Haptens are substances which develop to whole antigens only by binding to protein carriers. In otorhinolaryngology, delayed allergic hypersensitivities are apparent mainly as contact eczemata. Facial dermatitis, auricle and ear canal eczema as well as perioral eczema belong to the most common forms of contact dermatitis in ENT patients. The patient's medical history and morphology of the eczema give a strong indication for a proper diagnosis. Verification is carried out by patch test according to the Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF, The Association of the Scientific Medical Societies in Germany) guidelines. Hereby the most widespread contact allergens are tested in a so-called "standard block", which can be reduced to an individualized allergen spectrum, based on medical history. For therapy, allergen avoidance is the most important measure which should also be applied prophylactically. Moreover, antiinflammatory treatment of the contact eczema is carried out with tapering topical corticosteroids. Depending on the patient's age, location and severity of the contact eczema, newer class II or III preparations should be chosen. Skin care preparations are helpful to reduce corticosteroid consumption and are indicated additionally after the acute phase treatment. An important differential diagnosis of contact eczema is atopic dermatitis. Whilst contact dermatitis experiences healing by avoiding the triggering noxious agent, genetically determined atopic dermatitis shows a chronic, recurrent course. In addition to topical corticosteroids, calcineurin inhibitors have been approved for treatment of atopic eczema. In all eczema diseases, regular skin care is a necessary measure which contributes mainly to barrier repair.

Patch-test results in children and adolescents: systematic review of a 15-year period

The number of studies on patch-test results in children and adolescents has gradually increased in recent years, thus stimulating reviews. This paper is a systematic review of a 15-year period devoted to studying the issue. Variations pertaining to the number and age groups of tested children and/or adolescents, the number of subjects with atopy/atopic dermatitis history, the quantity, type and concentrations of the tested substances, the test technique and type of data regarding clinical relevance, must all be considered in evaluating these studies, as they make it harder to formulate conclusions. The most common allergens in children were nickel, thimerosal, cobalt, fragrance, lanolin and neomycin. In adolescents, they were nickel, thimerosal, cobalt, fragrance, potassium dichromate, and Myroxylon pereirae. Knowledge of this matter aids health professionals in planning preventive programs aimed at improving children's quality of life and ensuring that their future prospects are not undermined.

Guidelines of care for the management of atopic dermatitis: Section 4. Prevention of disease flares and use of adjunctive therapies and approaches

Atopic dermatitis is a common, chronic inflammatory dermatosis that can affect all age groups. This evidence-based guideline addresses important clinical questions that arise in its management. In this final section, treatments for flare prevention and adjunctive and complementary therapies and approaches are reviewed. Suggestions on use are given based on available evidence.

Allergic contact dermatitis in children: review of the past decade

Allergic contact dermatitis (ACD) is a type IV delayed hypersensitivity reaction. During the last decade, there has been a heightened awareness of this disease in the pediatric population. The gold standard for diagnosis is patch testing. The prevalence of positive patch tests in referred children with suspected ACD ranges from 27 to 95.6 %. The most common allergens in children in North America are nickel, neomycin, cobalt, fragrance, Myroxylon pereirae, gold, formaldehyde, lanolin/wool alcohols, thimerosal, and potassium dichromate. The relationship between ACD and atopic dermatitis (AD) is complicated with conflicting reports of prevalence in the literature; however, in a patient with dermatitis not responding to traditional therapies, or with new areas of involvement, ACD should be considered as part of the work-up.

Pattern of contact sensitization in patients with and without atopic dermatitis in a hospital-based clinical database

BACKGROUND

Both atopic dermatitis and contact sensitization are common conditions; however, a definite understanding of the relationship between contact sensitization and atopic dermatitis has not been reached.

OBJECTIVES

In this descriptive study, we investigated the differences between positive patch test reactions in patients with and without atopic dermatitis in a patch test cohort, and explored the influence of disease severity.

PATIENTS/MATERIALS/METHODS

Patch test results, information on atopic dermatitis and demographic variables were taken from a database, including all patients patch tested at Bispebjerg and Roskilde Hospitals from January 2009 to January 2013. Severe atopic dermatitis was defined as systemic therapy or hospitalization resulting from atopic dermatitis. All other patients with atopic dermatitis were defined as having mild/moderate disease.

RESULTS

The study included 2221 patients: 293 patients with atopic dermatitis and 1928 without. Forty-one per cent of patients with and 46.2% of patients without atopic dermatitis had at least one positive patch test reaction (p = 0.092). More patients with severe atopic dermatitis than patients with non-severe atopic dermatitis had multiple positive patch test reactions (19.4% versus 10.0%, p = 0.046).

CONCLUSIONS

Overall, we found similar frequencies of positive patch test reactions in patients with and without atopic dermatitis. However, a higher frequency of multiple sensitizations was found in patients with severe atopic dermatitis.

The multiple factors affecting the association between atopic dermatitis and contact sensitization

Atopic dermatitis and allergic contact dermatitis are both common skin diseases having an immune pathogenesis. There has been considerable interest about their inter-relationships with regard to altered susceptibility. Recent investigations have shed new light on this important question, and in this article, we explore whether there is evidence that atopic dermatitis affects the risk of contact sensitization and allergic contact dermatitis. The use of topical products to treat xerotic and inflamed skin in atopic dermatitis often results in a higher prevalence of sensitization to, for example, fragrances and other ingredients in emollients. Moreover, the prevalence of metal allergy seems to be increased, probably due to compromised chelation of the metals in the stratum corneum of patients with atopic dermatitis. However, conversely, the T-helper cell 2 bias that characterizes immune responses in atopic dermatitis appears to lower the risk of contact sensitization compared to healthy controls. Based on these observations, we conclude that multiple factors affect the association between atopic dermatitis and contact sensitization, and that these need to be appreciated in the clinical management of atopic dermatitis patients.

Allergic contact dermatitis in children: which factors are relevant? (review of the literature)

Allergic contact dermatitis (ACD) in children is increasing. Sensitization to contact allergens can start in early infancy. The epidermal barrier is crucial for the development of sensitization and elicitation of ACD. Factors that may influence the onset of sensitization in children are atopic dermatitis, skin barrier defects and intense or repetitive contact with allergens. Topical treatment of ACD is associated with cutaneous sensitization, although the prevalence is not high. ACD because of haptens in shoes or shin guards should be considered in cases of persistent foot eruptions or sharply defined dermatitis on the lower legs. Clinical polymorphism of contact dermatitis to clothing may cause difficulties in diagnosing textile dermatitis. Toys are another potentially source of hapten exposure in children, especially from toy-cosmetic products such as perfumes, lipstick and eye shadow. The most frequent contact allergens in children are metals, fragrances, preservatives, neomycin, rubber chemicals and more recently also colourings. It is very important to remember that ACD in young children is not rare, and should always be considered when children with recalcitrant eczema are encountered. Children should be patch-tested with a selection of allergens having the highest proportion of positive, relevant patch test reactions. The allergen exposure pattern differs between age groups and adolescents may also be exposed to occupational allergens. The purpose of this review is to alert the paediatrician and dermatologist of the frequency of ACD in young children and of the importance of performing patch tests in every case of chronic recurrent or therapy-resistant eczema in children.

Testing children for allergies: why, how, who and when: an updated statement of the European Academy of Allergy and Clinical Immunology (EAACI) Section on Pediatrics and the EAACI-Clemens von Pirquet Foundation

Allergic diseases are common in childhood and can cause a significant morbidity and impaired quality-of-life of the children and their families. Adequate allergy testing is the prerequisite for optimal care, including allergen avoidance, pharmacotherapy and immunotherapy. Children with persisting or recurrent or severe symptoms suggestive for allergy should undergo an appropriate diagnostic work-up, irrespective of their age. Adequate allergy testing may also allow defining allergic trigger in common symptoms. We provide here evidence-based guidance on when and how to test for allergy in children based on common presenting symptoms suggestive of allergic diseases.

Evaluation of the antiseptic efficacy and local tolerability of a polihexanide-based antiseptic on resident skin flora

OBJECTIVE

The primary objective of this study was to compare the antimicrobial efficacy of polihexanide 0.02% and 0.04% with chlorhexidine 0.05% after 30 minutes of topical treatment on healthy intact skin.

DESIGN

This study was performed as a double-blind, randomized, comparator-controlled, 3-arm, crossover study.

SETTING

: A phase I dermatological study unit.

PARTICIPANTS

Twenty healthy volunteers with intact skin.

INTERVENTIONS

: Test areas of 5 cm on the subjects' arms were treated with the investigational products using a polyurethane swab. Skin swabs were taken before and after treatment for quantitative microbial evaluation.

MAIN OUTCOME MEASURES

The main outcome measure was the log reduction factor of colony-forming units on the skin after 30 minutes of treatment.

MAIN RESULTS

No statistically significant difference was seen between both of the polihexanide test products (mean lgRF polihexanide 0.02%, 1.2251 [SD, 0.9399]; mean lgRF polihexanide 0.04%, 1.8991 [SD, 0.88]) and the comparator, chlorhexidine 0.05% (P > .1).

CONCLUSION

The results of this study indicate that polihexanide is a suitable alternative to chlorhexidine for skin and wound antisepsis.

The association between contact sensitization and atopic disease by linkage of a clinical database and a nationwide patient registry

BACKGROUND

Experimental studies have shown that individuals with atopic dermatitis are likely to have suppressed contact sensitivity secondary to their disease whereas some clinical and epidemiological studies have shown that individuals with atopic dermatitis might have a higher prevalence of contact sensitization than controls. The objective was to study the association between contact sensitization and, respectively, atopic dermatitis and asthma using clinical databases.

METHODS

Record linkage of two different registers was performed: (i) a tertiary hospital register of dermatitis patient's patch tested for contact sensitivity and (ii) the Danish National Patient Register containing nationwide hospital discharge diagnoses and outpatient contacts.

RESULTS

An inverse association was found between contact sensitization and, respectively, presumed severe atopic dermatitis (OR, 0.70; 95% CI, 0.61-0.81) and asthma (OR, 0.61; 95% CI, 0.42-0.90) when linkage was performed. Inverse associations were found for all groups of chemicals and metals except for sensitization to fragrances and topical drugs where positive associations were identified. A significant positive association between fragrance sensitization and presumed mild-moderate atopic dermatitis was also found when data from hospital register only were used, suggesting an overall higher prevalence of fragrance sensitization in patients with atopic dermatitis.

CONCLUSIONS

Our findings support that patients with severe atopic dermatitis and asthma have an overall lower prevalence of contact sensitization when compared with controls, whereas mild-to-moderate disease does not suppress contact sensitization. The prevalence of contact sensitization to fragrance chemicals was higher in patients with atopic dermatitis. Patients should be instructed to avoid scented moisturizers and products containing highly sensitizing substances.

[Allergic contact dermatitis and atopy]

Retrospective studies demonstrate that the prevalence of skin sensitization does not significantly differ between atopic and non-atopic patients. In children and adolescents the risk for sensitization seems to occur independently from AD. According to the results of a recent study, AD patients are overrepresented in the group of polysensitized patients. IgE-mediated sensitization as well as an early onset of AD and duration of the disease have been identified as possible risk factors for skin sensitization to contact allergens. A defective permeability barrier with increased epidermal water loss is a hallmark of AD and contributes to sensitization against common allergens. A highly significant association between FLG mutations and the risk of early onset, severe, persistent AD and an increased risk for asthma has been shown in several studies. A more recent study revealed an association between FLG mutations and increased nickel sensitization, but not other contact allergens. However, further large prospective studies with well-characterized patients are necessary to clarify the correlation between impaired skin barrier, atopic dermatitis and allergic contact dermatitis.

Iatrogenic skin injury in hospitalized patients

Iatrogenic skin injuries in hospitalized patients range from drug-related complications to those related to procedures. Common drug complications include drug reaction with eosinophilia and systemic symptoms (DRESS), linear immunoglobulin (Ig) A bullous dermatosis, Stevens-Johnson syndrome/toxic epidermal necrolysis, and acute generalized exanthematous pustulosis. Contact dermatitis can result from surgical preparations of chlorhexidine and povidone-iodine, medical adhesives, topical postsurgical ointments, most commonly neomycin and bacitracin, and internal prostheses, including coronary stents, pacemakers, and metal joints. Complications arising from procedures include thrombosis caused by placement of peripherally inserted central catheters, pyoderma gangrenosum from sites of dermal trauma, and anetoderma of prematurity from cutaneous monitoring devices in neonates. Calcinosis cutis and decubitus ulcers are also hospital problems.

Allergic contact dermatitis to chlorhexidine in a very young child

Allergic contact dermatitis to chlorhexidine is an unusual condition, with sensitization in childhood rarely reported. We report the observation of allergic contact dermatitis to chlorhexidine in a 23-month-old boy.

Flaky tail mouse denotes human atopic dermatitis in the steady state and by topical application with Dermatophagoides pteronyssinus extract

The barrier abnormality, a loss-of-function mutation in the gene encoding filaggrin (FLG), which is linked to the incidence of atopic dermatitis (AD), is a recently discovered but important factor in the pathogenesis of AD. Flaky tail (Flg(ft)) mice, essentially deficient in filaggrin, have been used to investigate the role of filaggrin on AD. However, the relevancy of Flg(ft) mice to human AD needs to be determined further. In this study, we observed the clinical manifestations of Flg(ft) mice in the steady state and their cutaneous immune responses against external stimuli, favoring human AD. Under specific pathogen-free conditions, the majority of Flg(ft) mice developed clinical and histological eczematous skin lesions similar to human AD with outside-to-inside skin barrier dysfunction evaluated by newly devised methods. In addition, cutaneous hapten-induced contact hypersensitivity as a model of acquired immune response and a mite extract-induced dermatitis model physiologically relevant to a human AD were enhanced in Flg(ft) mice. These results suggest that the Flg(ft) mouse genotype has potential as an animal model of AD corresponding with filaggrin mutation in human AD.

Contact dermatitis in children

Contact dermatitis in pediatric population is a common but (previously) under recognized disease. It is usually divided into the allergic and the irritant forms.

The diagnosis is usually obtained with the patch test technique after conducting a thorough medical history and careful physical examination but patch testing in infants may be particularly difficult, and false-positive reactions may occur.

This study also provides an overview of the most common allergens in pediatric population and discusses various therapeutic modalities.

Reactions to Aquaphor: is bisabolol the culprit?

Bisabolol is a sesquiterpene alcohol compound derived from the German chamomile plant, a member of the Compositae family. Only two case reports of adults with allergic contact dermatitis to this chemical exist in the literature, and we describe three more cases of children with recalcitrant atopic dermatitis found to have potential allergic contact dermatitis to bisabolol- a component of the Aquaphor emollient they were using to treat their atopic dermatitis. Of note, Compositae dermatitis has been shown to have a higher prevalence in children with atopic dermatitis, so it is important for physicians to be aware of the potential allergens (like bisabolol) in products they are recommending as first line treatments.