Pediatric allergic contact dermatitis. Part I: Clinical features and common contact allergens in children

Triggered Skin Sensitivity: Understanding Contact Dermatitis

Dermatitis, the incendiary reaction of the skin to various components, can manifest in various types, including atopic dermatitis, contact dermatitis, nummular eczema, seborrhoea, and stasis dermatitis. Atopic dermatitis is the most common skin disease in children and has a growing prevalence in recent years. It is characterized by extreme tingling, eczemous skin injuries, dryness of the skin, and a family history of atopic illnesses. Contact dermatitis (CD) is a common, irritating skin disorder caused by allergens and aggravating elements in the environment. It is the most common cause of work-related dermatitis and plays a substantial role in hand and face dermatitis. A complete restorative history is essential for establishing CD and identifying the allergies that cause it. Fix testing, skin tests for fast contact reactions, serum allergen-specific IgE testing, subjective and quantitative evaluation of allergens inside probable items patients were exposed to, and challenge testing are among the other diagnostic techniques. To avoid a breakdown and the continuation of the skin illness, early and suitable therapy is critical. Allergic dermatitis to contact (ACD) develops during the normal, delayed incendiary reaction and has a perplexing etiology. Accurate identification of the allergen that is causing the reaction allows for adequate individual avoidance. The major treatment alternatives continue to be corticosteroids. Nickel-contact dermatitis is an allergic reaction that affects both children and adults. Adverse contact dermatitis (ACD) is a frequent skin reaction to a common allergen that can affect both children and adults. Less than 10% of all diagnostic procedures in pediatric patients involve checking for ACD symptoms. To answer the clinical question, a thorough history is gathered based on appearance, age group, and dermatitis type. According to pediatricians in the US, metals, perfumes, topical antimicrobials, excessive chemicals, and fabric softeners are the most typical allergens.

[Inflammatory dermatoses in children and adolescents : Diagnosis and treatment of atopic dermatitis and psoriasis]

Atopic dermatitis (AD) and psoriasis belong to the most common inflammatory dermatoses that we treat in everyday clinical practice. AD manifests in more than 70% of cases before the age of 5 years. Approximately one-third of psoriasis patients report on onset of disease in the first two decades of life. Here, we are going to review both disorders in the light of pediatric dermatology. We are going to discuss selected subtypes and present clues for further examination with respect to the differential diagnoses and comorbidities. The article provides insight into current therapeutic developments that are relevant for the treatment of children and adolescents.

The Involvement of Cysteine-X-Cysteine Motif Chemokine Receptors in Skin Homeostasis and the Pathogenesis of Allergic Contact Dermatitis and Psoriasis

Members of the C-X-C motif chemokine receptor (CXCR) superfamily play central roles in initiating the innate immune response in mammalian cells by orchestrating selective cell migration and immune cell activation. With its multilayered structure, the skin, which is the largest organ in the body, performs a crucial defense function, protecting the human body from harmful environmental threats and pathogens. CXCRs contribute to primary immunological defense; these receptors are differentially expressed by different types of skin cells and act as key players in initiating downstream innate immune responses. While the initiation of inflammatory responses by CXCRs is essential for pathogen elimination and tissue healing, overactivation of these receptors can enhance T-cell-mediated autoimmune responses, resulting in excessive inflammation and the development of several skin disorders, including psoriasis, atopic dermatitis, allergic contact dermatitis, vitiligo, autoimmune diseases, and skin cancers. In summary, CXCRs serve as critical links that connect innate immunity and adaptive immunity. In this article, we present the current knowledge about the functions of CXCRs in the homeostasis function of the skin and their contributions to the pathogenesis of allergic contact dermatitis and psoriasis. Furthermore, we will examine the research progress and efficacy of therapeutic approaches that target CXCRs.

Results of the patch tests with European baseline series in children: Five years of experience from a single center in Turkey and a review of the literature

BACKGROUND

Pediatric allergic contact dermatitis (ACD) is increasingly prevalent. Patch testing is the gold-standard diagnostic method.

AIMS

Our study aimed to identify common contact-sensitizing allergens in Turkish children.

PATIENTS/METHODS

We retrospectively analyzed the patch test results and characteristics of 191 pediatric patients [114 (59.7%) females, 77 (40.3%) males], who received the diagnosis of allergic contact dermatitis between 2015 and 2019.

RESULTS

The mean age of the patients was 12.2 years (range 4-18 years). Thirty-six (18.8%) of the patients in the study group had positive patch test outcomes with 56 positive allergens. Girls had a significantly higher rate of total positive patch test results than boys (75%/25%; p = 0.003, p < 0.05). The most frequent four allergens were nickel sulfate (n = 20, 10.4%), cobalt chloride (n = 6, 3.14%), p-phenylenediamine (n = 5, 2.61%), Methylchloroisothiazolinone/methylisothiazolinone (n = 5, 2.61%), respectively.

CONCLUSIONS

In our study, we discovered that in addition to the frequently encountered metal allergens such as nickel and cobalt, p-phenylenediamine and Methylchloroisothiazolinone/methylisothiazolinone sensitivities were frequent in the Turkish population. p-phenylenediamine sensitization can cause serious systemic dermatitis during the lifetime of children. We suggest that in Turkey personal care and hygiene products containing Methylchloroisothiazolinone/methylisothiazolinone should be legally regulated. Since childhood contact dermatitis may have an impact on the quality of life by influencing family and social life, suspected allergens should be detected as early as possible.

Early-Life Exposure to Formaldehyde through Clothing

Clothes contain a wide range of chemicals, some of them potentially hazardous. Recently, there has been a growing interest in eco-friendly clothing, including the use of organic cotton. However, the process of eco-friendly fabric production does not exclude the use of toxic substances, such as formaldehyde, a known human carcinogen. The present investigation was aimed at determining the presence of formaldehyde in eco-friendly and conventional clothing of pregnant women, babies, and toddlers from the Catalan (Spain) market. The potential effects of washing were also investigated by comparing the reduction of formaldehyde in unwashed and washed clothing. Formaldehyde was detected in 20% of samples, with a mean level of 8.96 mg/kg. Formaldehyde levels were surprisingly higher in eco-friendly than in regular garments (10.4 vs. 8.23 mg/kg). However, these differences were only significant (p < 0.05) for bras (11.6 vs. 7.46 mg/kg) and panties (27.1 vs. 6.38 mg/kg) of pregnant women. Dermal exposure and health risks were assessed for three vulnerable population groups: pregnant women, babies, and toddlers. In general, exposure was higher in babies (up to 1.11 × 10−3 mg/kg/day) than in other groups (2.58 × 10−4 and 4.50 × 10−3 mg/kg/day in pregnant women and toddlers, respectively). However, both non-carcinogenic and carcinogenic risks were below the safety limits (<1 and <10−5, respectively) according to national regulations. Notwithstanding, although formaldehyde levels were below the legal limits (<75 mg/kg) and health risks were within acceptable ranges, clothing may contain other toxic substances in addition to formaldehyde, thus increasing the risks. Finally, since no formaldehyde was detected in washed textile samples, a safe and simple practice for the consumers is to wash clothing before the first use.

Contact allergens in moisturizers in preventative emollient therapy – A systematic review

Background

Results of preventative emollient therapy on atopic dermatitis and food allergy trials are inconsistent. In addition to the ingredients considered beneficial, the moisturizers may contain potentially harmful haptens. This study aimed to assess the prevalence of haptens in moisturizers used in studies to prevent atopic dermatitis or food allergy and assess their correlations to the trial results.

Methods

A systematic search of studies investigating the role of emollient usage in preventing atopic dermatitis or food allergy in infants was performed from inception to December 2020. Haptens were identified based on the nine common patch test series (European, American, and Australian).

Results

12 clinical trial studies were included in the review. In total, 16 different emollients were applied as an intervention. The vast majority (75%) of preparations contained at least one hapten from which several substances pose high allergic or irritant potential. Quantitative data synthesis of the findings regarding food allergy and atopic dermatitis prevention was not possible due to the significant heterogeneity of preparations used.

Conclusions

Careful selection of emollient should consider the absence of potentially harmful ingredients, particularly when used in youngest children. Chronic skin exposure to haptens promotes the development of allergic contact dermatitis and moreover, via deterioration of the skin barrier and subclinical inflammation, may facilitate epicutaneous sensitization and promote atopic dermatitis; however further research is needed to validate our suppositions.

Sensitizing agents found in children and adolescents with recalcitrant atopic dermatitis: a cross-sectional study with a pediatric battery

BACKGROUND

Atopic dermatitis is the most common inflammatory skin disease in childhood and has an important impact on quality of life, especially severe cases or those that are recalcitrant to treatments. Sensitization to allergens with the potential for allergic contact dermatitis is a factor associated with cases of recalcitrant atopic dermatitis. Understanding the relationship between atopic dermatitis, allergens, and allergic contact dermatitis is essential. In Brazil, there are no studies on sensitization to allergens found in patch tests with pediatric batteries in patients with atopic dermatitis.

OBJECTIVES

To verify the main sensitizing agents, the prevalence of allergic contact dermatitis and the epidemiological and clinical profile of children and adolescents with atopic dermatitis.

METHODS

Cross-sectional, prospective study in patients between 4 and 18 years of age, with recalcitrant atopic dermatitis, treated at the Sanitary Dermatology Outpatient Clinic (RS). All patients underwent patch tests with a battery of pediatric allergens.

RESULTS

The prevalence of sensitization and allergic contact dermatitis in the evaluated patients was 37.07% (20/54) and 27.7% (15/54), respectively. The most frequent allergens were: nickel sulfate (16.7%), disperse blue (5.6%), and fragrance mix I (5.6%). Nickel was associated with the female sex (p = 0.019).

STUDY LIMITATIONS

Sample size and selection, absence of a control group.

CONCLUSIONS

A proportion of patients with recalcitrant atopic dermatitis may be sensitized to different allergens and may even have developed allergic contact dermatitis. Recognizing this context is important in the prevention strategy and management of the disease.

Consort Allergic Contact Dermatitis: A Systematic Review

ABSTRACT

Consort allergic contact dermatitis (CACD) develops following exposure to an allergen originating from another individual. The diagnosis is often not straightforward. We conducted a systematic review to characterize patient demographics, clinical features, consort types, responsible products, and associated allergens in CACD. A literature search was conducted in PubMed, EMBASE, Web of Science, and CINAHL Complete from inception to July 2020. In total, 183 articles describing 261 patients with CACD were included. Mean age was 40.9 years with female predominance (62.8%). The most common body sites involved were the face (48.6%), hand (30.4%), arm (20.9%), neck (17.8%), and genitals (11.5%). The most common consorts were partners/spouses (50.0%, of which 29.9% were related to sexual activity), children (19.4%), and healthcare providers (7.8%). Allergens were mainly encountered via direct contact with consorts (80.5% of cases). A caregiver relationship was involved in 27.6% of cases, and the consort's occupation in 14.6%. The most frequently implicated products were medications (35.6%), plants/botanicals (11.7%), and fragrances (8.7%). Patch testing identified 125 unique allergens in CACD. CACD can occur in relation to many individuals encountered throughout life. Caregivers may represent a high-risk group for developing CACD. Obtaining a holistic history encompassing social, sexual, and occupational factors can aid in the diagnosis.

Contact allergy in children with and without atopic dermatitis: an Italian multicenter study

Background

Contact allergy and atopic dermatitis (AD) are both common inflammatory T cell‐mediated diseases and many factors may influence the prevalence of contact allergy in AD patients. In children, their possible correlation was debated with conflicting results.

Objectives

The present study aimed to assess the prevalence of contact sensitivity in children and to investigate the association with AD.

Materials and methods

A retrospective multicentre study on children aged from 0 to 14 years patch tested between January 2017 and December 2018 was performed. Children were consecutively patch tested with the SIDAPA (Società Italiana Dermatologia Allergologica Professionale Ambientale) baseline series.

Results

Among the 432 children investigated for contact allergy, 125 (28.9%) showed a positive reaction to at least one of the allergens tested, with a higher prevalence of positive patch test reactions in girls (32.3%) than in boys (25.0%). The most frequent contact allergens were nickel sulphate (10.2%), cobalt chloride (6.7%), methylisothiazolinone (3.7%), fragrance mix‐2 (3.2%), potassium dichromate (2.8%), fragrance mix‐1 (2.1%) and methylchloroisothiazolinone/methylisothiazolinone (2.1%). One‐hundred‐three children (23.8%) suffered from AD showing a higher prevalence of positive patch test (36.9%) compared to children without AD (26.4%).

Conclusions

Despite the topic being still controversial, the present study suggests a consistent prevalence of contact allergy among children with higher sensitivity rate among children with AD than without AD.

What We Have Learned–Milestones in Pediatric Contact Dermatitis

Purpose of Review

This review highlights recent developments in the field of pediatric allergic contact dermatitis (ACD) and patch testing. We will review updates on the pathophysiology of contact dermatitis, discuss new contact allergens, explore the impact of dupilumab on patch testing, and provide pearls for the diagnosis and management of ACD in children.

Recent Findings

ACD is not a single immunologic phenomenon but rather has contributions from multiple inflammatory pathways. Emerging contact allergens include ingredients found in “slime” toys, glucose monitors and insulin pumps, and electronic equipment. Data thus far suggests that patch testing results are generally reliable in the face of concurrent dupilumab use.

Summary

ACD is likely underrecognized and underdiagnosed in pediatric patients, including infants and young children. Providers should keep patient-specific factors and emerging trends in mind when addressing suspected ACD, consider contact dermatitis when they encounter challenging cases of atypical, refractory, or chronic dermatitis, and feel comfortable performing patch testing in children.

Changes in Product Use and Quality of Life After Patch Testing in Children With Allergic Contact Dermatitis: A Follow-up Survey

BACKGROUND

Patch testing is the criterion standard to diagnose allergic contact dermatitis (ACD).

OBJECTIVE

This study assessed the value of patch testing for product changes and quality of life in children with ACD.

METHODS

In this cross-sectional survey, we used a questionnaire to follow up with families of ACD patients about changes since patch testing and counseling preferences. Eligible participants were 18 years or younger during expanded series or personalized patch tests at the Washington University School of Medicine from 2007 to 2020.

RESULTS

Of the 43 enrolled participants, most were positive for multiple allergens (63%) and changed personal products after patch testing (71%). Only 26% of the families consistently read product labels before patch testing, compared with 66% after. Patients saw a mean relative reduction of 49% in severity of rash (8.2-4.2 of 10), 46% in interference with activities (5.7-3.1), and 51% in self-consciousness (7.0-3.4) since patch testing. Families gave favorable feedback for counseling on products to avoid (9.4 of 10 average rating of usefulness), product recommendations (8.5 of 10), and chemical names (7.9 of 10).

CONCLUSIONS

Patch testing can lead to meaningful improvements in quality of life for most children with ACD. Counseling on positive results should include discussion of specific products to use and avoid.

Contact allergy in a paediatric population observed in a tertiary referral centre in Belgium

BACKGROUND

Contact allergy is increasingly recognized as being important in children with eczema.

OBJECTIVES

To retrospectively analyse the patch test results in children over the past 10 years, aiming to (1) evaluate demographic characteristics and lesion locations, (2) describe frequencies of positive patch test reactions, and (3) investigate the relationship with atopic dermatitis (AD).

METHODS

A total of 329 children were patch tested between January 2010 and December 2019 with the European (children) baseline series and/or other series, and the personal product(s) used.

RESULTS

A total of 119 (36%) children presented with at least one positive reaction. Children with AD had a higher prevalence of positive reactions compared with the non-AD group (P = .002), but without statistically significant difference regarding sensitization to more than one hapten (P = .39). The face (20.2%), hands (19.3%), feet (16.8%), arms (12.6%), and body folds (10.9%) were the most common sites of primary localizations. The most frequent contact allergens were nickel sulfate and linalool hydroperoxide (both 16%), limonene hydroperoxide (13.5%), and para-phenylenediamine (10.9%). No statistically significant difference for nickel sulfate was found between the AD and non-AD group (P = .20).

CONCLUSIONS

Contact allergy in children with eczema was frequently observed in our tertiary referral centre in Belgium as well, confirming the need for patch testing.

Age-related differences in patch testing results among children: Analysis of North American Contact Dermatitis Group Data, 2001-2018

BACKGROUND

An updated understanding of allergic contact dermatitis is needed, particularly in children.

OBJECTIVES

To compare positive and clinically relevant reactions in children versus adults referred for patch testing.

METHODS

Retrospective analysis of 1871 children and 41,699 adults from the North American Contact Dermatitis Group (NACDG) from 2001-2018.

RESULTS

Both final diagnosis of allergic contact dermatitis (55.2% versus 57.3%; chi square, P = .0716) and prevalence of ≥ 1 currently relevant reaction to a NACDG screening allergen (49.2% vs 52.2%; P = .1178) were similar between children and adults. Currently in children, the most common relevant allergens were nickel sulfate (17.3%), hydroperoxides of linalool (7.8%), methylisothiazolinone (7.7%), cobalt chloride (7.0%), and fragrance mix I (4.9%). Approximately a fifth of children had a positive reaction to a non-NACDG allergen.

CONCLUSION

Over half of children referred for patch testing were diagnosed with allergic contact dermatitis. The most common relevant allergens in children were nickel sulfate, cobalt chloride, and hydroperoxides of linalool. Twenty percent of children had at least 1 positive reaction to allergens/substances not on the NACDG screening series, underscoring the need for comprehensive testing.