Contact Urticaria Syndrome: a Comprehensive Review

A Practical Approach to Chronic Hand Eczema

Chronic hand eczema (CHE) is a multifactorial condition with significant physical, psychological, and socioeconomic burdens. Its complex pathogenesis often does not align with clinical presentation, leading to overlapping etiologic subtypes, including allergic contact dermatitis (ACD), irritant contact dermatitis (ICD), and atopic hand eczema (AHE). While patch testing remains the gold standard for confirming ACD, its clinical utility can be limited owing to frequent subtype overlap, impracticality of allergen avoidance, and practical considerations relating to the process and availability of patch testing itself. This review provides a practical, clinician-oriented framework for managing CHE, emphasizing the importance of clinical judgment in deciding when patch testing is indicated versus when prompt treatment should take priority. We explore the role of patch testing in CHE within the context of real-world practice, incorporating global perspectives where they inform practical clinical decision-making. With the emergence of targeted therapies addressing CHE immunopathogenesis, balancing traditional diagnostic approaches with early, effective treatment is increasingly necessary. A streamlined, patient-centered strategy balancing diagnostic thoroughness with timely interventions may aid clinicians in optimizing outcomes in this complex disease.

Contact Urticaria Testing at a Specialized Contact Dermatitis Clinic: Our Experience Over 5 Years

Background: Distinguishing between contact urticaria and allergic contact dermatitis can be challenging, and some patients may exhibit a combination of immediate and delayed-type reactions. Patients with suspected contact allergy are often referred to specialized patch testing centers, some of which may not offer contact urticaria testing. Objective: To examine the role of contact urticaria testing at our institution, specifically analyzing its ability to unveil reactions not detected during standard patch testing. Methods: Retrospective study of 2,396 patients comprehensively patch tested over a 5-year period. For each allergen in our contact urticaria series, positive reactions were assessed for concordant reactions on standard patch testing. A separate analysis including cross-reactors was conducted for fragrance and benzoate allergens. Results: Of 31 patients who received both contact urticaria and standard patch testing, 24 exhibited at least 1 positive contact urticaria reaction, amounting to 73 total reactions. 86% (63/73) of these reactions were identified with contact urticaria testing only. Conclusions: In our experience, contact urticaria testing revealed reactions not demonstrated during standard patch testing. Standardized contact urticaria testing protocols may result in improved diagnosis and disease clearance. Thus, patch testing centers might consider performing contact urticaria testing for patients with immediate-onset symptoms.

A Review of Hand Eczema Subtypes: Clinical Features, Biomarkers and Treatment Strategies

Hand eczema is a common dermatological condition that significantly impairs quality of life. The classification of hand eczema has been considered an essential step for its management. The diagnosis of hand eczema relies on the aetiological and clinical features of hand lesions, a process complicated by the heterogeneous presentations and the considerable overlap among its subtypes. However, the investigation of hand eczema biomarkers and the advent of targeted therapies have shed light on the underlying pathogenic mechanisms. This review adopts a subtype-specific approach to hand eczema, addressing clinical, pathogenic and therapeutic factors, with the aim of providing a comprehensive understanding of this heterogeneous condition from the perspective of its subtypes.

[Food allergy as occupational disease]

BACKGROUND

Food-induced allergic reactions not only occur in private settings but also in occupational context. In these cases, the presence of an occupational disease should be investigated. We provide an overview of selected food-associated occupational diseases.

METHODS

A literature search was conducted on food-associated occupational dermatoses (contact urticaria, protein contact dermatitis) and occupational food anaphylaxis.

RESULTS

Food allergy as an occupational disease is usually manifested as respiratory or cutaneous symptoms, while food anaphylaxis is rarely reported. Employees in food processing industries, in particular cooks and workers in the fishing and meat industry as well as employees in the bakery and pastry industries, represent a highly exposed group for food-associated occupational dermatoses, occupational asthma and food anaphylaxis.

CONCLUSION

The possible triggers for occupational food allergies are diverse and can range from foods of animal origin (meat, fish, dairy products) to various plant-derived allergens and food additives (e.g. carmine E120, enzymes). A precise exposure history and allergological diagnostics are crucial in cases of suspected occupational food allergy.

Regulatory frameworks for fragrance safety in cosmetics: a global overview

Fragrances play a crucial role in cosmetic products, influencing consumer preferences and enriching sensory experiences. However, making sure these products are safe, especially concerning natural and synthetic fragrances, requires robust regulatory frameworks. This review offers a global perspective on the regulatory systems governing the safety of fragrances. It begins by examining the fundamental differences between natural and synthetic fragrances, highlighting their origins and unique safety considerations. Natural fragrances, sourced from botanicals like essential oils, have a long history of human exposure. Synthetic fragrances, on the other hand, are artificially manufactured compounds that often lack sufficient safety data, thereby requiring strict regulation. Various countries have developed safety guidelines to address concerns such as skin sensitization, allergies, and health risks associated with fragrance use. This article provides a comprehensive analysis of these global regulatory frameworks, emphasizing both commonalities and disparities in safety standards for natural and synthetic fragrances. It also discusses ongoing efforts to harmonize regulations and improve fragrance safety in cosmetics. By offering this in-depth overview of regulatory approaches, the article serves as a valuable resource for cosmetics industry professionals. It provides insights into the evolving landscape of cosmetics regulations worldwide, aiding stakeholders in navigating the complexities of natural and synthetic fragrance safety and ultimately safeguarding consumer well-being.

Graphical Abstract

Chronic Hand Eczema, Real World, and Patient Centricity: A Narrative Review

Chronic hand eczema is a multifactorial, fluctuating, inflammatory skin disease of the hands and wrists, defined as hand eczema that persists for at least 3 months or recurs at least twice within 1 year. Chronic hand eczema is heterogeneous in nature with different clinical manifestations. This chronic condition can significantly impact daily activities and health-related quality of life for patients, including notable physical, psychosocial, occupational, and socioeconomic burdens. However, awareness of the disease and the patient experience remains poor. This review aims to improve understanding of chronic hand eczema in the context of its underlying pathogenesis, clinical subtypes and presentation, and risk factors. Additionally, an overview of the patient experience of the disease, including health-related quality of life and socioeconomic implications, is provided. Improved understanding of chronic hand eczema will support optimal patient care by empowering healthcare providers to more quickly and correctly diagnose this disease with high unmet treatment needs and subsequently offer appropriate holistic care.

Moisturizer induced contact anaphylaxis

BACKGROUND

Contact allergens typically trigger localised reactions, but systemic Type I hypersensitivity from skin contact reactions are rare.

CASE PRESENTATION

We present the case of a 69-year-old non-atopic male who developed anaphylaxis following the application of moisturizer to an area of chemical burns. Skin testing showed a strong positive result to moisturizer. Whilst not all ingredients were available for testing, phenoxyethanol was thought to be the likely culprit agent based on literature review and a weakly positive skin test result.

CONCLUSION

Products such as moisturizers can rarely trigger anaphylaxis, especially when applied to damaged skin which may favor systemic absorption. This case highlights the need for careful consideration of cosmetic application when discerning culprit allergens.

Hand eczema

Hand eczema is a highly prevalent skin disease and one of the most common work-related disorders. In up to two-thirds of individuals affected by hand eczema, the disease becomes chronic and results in substantial personal and occupational disability. Manifestations of chronic hand eczema vary in severity and appearance over time, and people with eczema typically experience itch, pain, and a burning sensation. The pathophysiology of chronic hand eczema is multifactorial. Major risk factors are current or past atopic dermatitis and excessive or prolonged exposure to irritants or allergens. Based on the suspected main causes, chronic hand eczema is commonly classified into irritant, allergic, and atopic hand eczema. Diagnosis and assessment can be complex, and management is often challenging. Strategies include structured education, avoidance of trigger factors, primary to tertiary prevention, topical anti-inflammatory treatment with glucocorticosteroids, calcineurin inhibitors, or januskinase inhibitors, phototherapy, systemic retinoids, and off-label use of immunosuppressive drugs. Topical and systemic immunomodulatory therapies approved for atopic dermatitis could be used in severe atopic hand eczema and some of them are under clinical development for chronic hand eczema. Additional research is needed to better understand chronic hand eczema subtypes and underlying mechanisms, and the comparative effectiveness and safety of therapies. This Review combines established knowledge with ongoing changes in our understanding of the disease and their implications for prevention, management, and future research.

Occupational Contact Dermatitis in Firefighters

Occupational contact dermatitis (OCD) emerges as a salient concern within the context of firefighters, a professional cohort routinely exposed to an array of hazardous substances as an intrinsic facet of their occupational responsibilities. This continual skin exposure to a spectrum of allergenic and irritant agents engenders an elevated predisposition to OCD among firefighters. Notably, the ramifications of OCD in the domain of occupational health assume substantial import, contributing significantly to the prevalence of work-related dermatological maladies and consequential productivity decrements. However, it is conspicuous that the extant body of scholarly literature addressing the specific incidence of OCD in the firefighter demographic remains limited. To address this knowledge gap, we undertake a comprehensive inquiry into the phenomenon of OCD within the firefighter population. Our framework systematically classifies OCD into 3 discrete categories: allergic contact dermatitis, irritant contact dermatitis, and contact urticaria. Within each of these categories, we explore the various etiologies. Furthermore, our review highlights the multifaceted nature of OCD in firefighters and offers valuable insights into tailored preventive measures to mitigate its occurrence within these essential frontline workers. Our aim is to offer a comprehensive perspective on this occupational health issue and provide firefighters with practical strategies to protect their skin health while they continue their vital work in safeguarding our communities.

Differential diagnosis of contact dermatitis: A practical-approach review by the EADV Task Force on contact dermatitis

The diagnosis of eczema ('dermatitis') is mostly clinical and depends on the clinical history and exploratory objective findings (primary lesions, patterns). Contact dermatitis remains as an important condition in the group of eczematous disorders, with important socioeconomic and occupational relevance. Although irritant and allergic contact dermatitis have a different pathogenesis, both are characterized by a rather typical morphology, are triggered by external factors and tend to occur primarily in the area of contact with the exogenous agent. In addition, allergic and irritant dermatitis may also co-exist. The importance of diagnosing contact dermatitis, especially when allergic in nature, is both due to the possibility of avoiding the trigger, and due to its role in aggravating other skin conditions. Nevertheless, the heterogeneity of clinical presentations in daily practice may pose an important challenge for the suspicion and correct diagnosis of contact dermatitis. Furthermore, other conditions, with different pathogenesis and treatment, may clinically simulate contact dermatitis. The Task Force aims to conduct a review of the unifying clinical features of contact dermatitis and characterize its main clinical phenotypes, and its simulators, in order to contribute to an early suspicion or recognition of contact dermatitis and enable a correct differential diagnosis.

How Allergists Can Perform an Occupational History in Every Patient

The occupational history is often neglected in the routine evaluation of new patients with asthma, chronic rhinitis, or dermatologic complaints. Such omissions are inadvertent because work-related conditions are often not prioritized. There also may be lack of awareness of the scope of respiratory or cutaneous allergens capable of inducing occupational asthma (OA) or work-related contact dermatitis. Evidence exists suggesting that the occupational history is often neglected among primary care physicians and specialists. Failure to diagnose OA in a timely fashion by identifying occupational sources of exposure, for example, may result in unnecessary morbidity in workers whose exposure is not modified. In this commentary, we propose a brief intake survey to be administered to all patients coming to an allergy practice to quickly screen for possible work-related respiratory symptoms and another for occupational dermatitis. This would require minimal physician time and could be self-administered at the initial encounter and incorporated into the medical record. A positive response to either survey should trigger a more detailed evaluation by the allergy specialist. More detailed approaches for stepwise clinical evaluation of the worker suspected of OA and contact dermatitis are discussed.

Potential for Glove Risk Amplification via Direct Physical, Chemical, and Microbiological Contamination

This review focuses on the potential direct physical, chemical, and microbiological contamination from disposable gloves when utilized in food environments, inclusive of the risks posed to food products as well as worker safety. Unrecognized problems endemic to glove manufacturing were magnified during the COVID-19 pandemic due to high demand, increased focus on PPE performance, availability, supply chain instability, and labor shortages. Multiple evidence-based reports of contamination, toxicity, illness, deaths, and related regulatory action linked to contaminated gloves in food and healthcare have highlighted problems indicative of systemic glove industry shortcomings. The glove manufacturing process was diagramed with sources and pathways of contamination identified, indicating weak points with documented occurrences detailed. Numerous unsafe ingredients can introduce chemical contaminants, potentially posing risks to food and to glove users. Microbial hazards present significant challenges to overall glove safety as contaminants appear to be introduced via polluted water sources or flawed glove manufacturing processes, resulting in increased risks within food and healthcare environments. Frank and opportunistic pathogens along with food spoilage organisms can be introduced to foods and wearers. When the sources and pathways of glove-borne contamination were explored, it was found that physical failures play a pivotal role in the release of sweat build-up, liquefaction of chemical residues, and incubation of microbial contaminants from hands and gloves. Thus, with glove physical integrity issues, including punctures in new, unused gloves that can develop into significant rips and tears, not only can direct physical food contamination occur but also chemical and microbiological contamination can find their way into food. Enhanced regulatory requirements for Acceptable Quality Limits of food-grade gloves, and the establishment of appropriate bioburden standards would enhance safety in food applications. Based on the information provided, together with a false sense of security associated with glove use, the unconditional belief in glove chemical and microbiological purity may be unfounded.

Hair Product Allergy: A Review of Epidemiology and Management

Allergy to hair products is an increasingly common issue among people given the exposure to these products on a daily basis. Allergic reactions could be in the form of delayed-type contact dermatitis or the form of immediate-type hypersensitivity reactions. Hair products contain many ingredients and chemicals that patients may have allergies to, but common allergens are hair dyes, fragrances, persulfate salts, ammonium thioglycolate, coconut fatty acid derivatives, and acrylates. Allergy to hair dye is the most common followed by other allergens such as fragrances and persulfate salts. We discussed testing for hair dye allergy along with suggestions for alternative hair dyes that patients may use. Allergy to topical scalp medications is also seen in patients using those products. Allergy to topical minoxidil is seen more often due to the increased use of minoxidil sprays and foams among patients to increase hair growth. We will discuss in this review the diagnosis and alternatives for patients with minoxidil allergy. Hairdressers are at higher risk of allergy to hair products compared to the general population due to prolonged exposure to allergens and specific measures should be implemented to minimize the hazards of exposure.

Diagnostics and Prevention of Occupational Allergy in Hairdressers

PURPOSE OF REVIEW

This study aims to provide an overview on current knowledge on occupational allergic diseases in hairdressers and up-to-date perspectives of prevention.

RECENT FINDINGS

Hand eczema (dermatitis) is common in hairdressers, often caused by contact allergy to one or multiple small molecules (haptens) used, e.g., for dyeing, bleaching, and waving/relaxing or by ancillary substances such as preservatives. Hairdressers, compared to other patch-tested patients, have an up to fivefold increased risk to be found sensitized, e.g., against p-phenylenediamine, ammonium persulfate, and glyceryl thioglycolate. Some of these small molecules may induce respiratory sensitization causing allergic rhinitis and/or asthma, notably persulfate salts. Occupational hazards in hairdressing are well described. This knowledge needs to be put into use for risk reduction, mainly by substitution of allergenic ingredients by less allergenic ones, education, and use of ventilation and suitable single-use gloves.

Occupational Hand Dermatitis

PURPOSE OF REVIEW

Occupational hand dermatitis is a common work-related disorder of the skin. Prevention and management of this disease is critical to improving workers' quality of life and for occupation-specific retention.

RECENT FINDINGS

This is a critical review of the current literature on occupational hand dermatitis. Occupational dermatitis continues to have a high prevalence among workers although the overall incidence may be slowly decreasing. Irritant contact dermatitis due to wet work exposure is the most common cause of occupational hand dermatitis. Healthcare workers, hairdressers, and metal workers are at particularly high risk for this disease. While some prevention programs have been ineffective in mitigating occupational hand dermatitis, other more resource-intensive initiatives may have benefit. Continued research is needed on ways to manage wet work exposures and on scalable, effective prevention programs for occupational hand dermatitis. The spectrum of culprit contact allergens continues to evolve, and vigilance for potential occupation-specific allergens remains important.