Allergic contact dermatitis

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.

Role of Innate Immunity in Allergic Contact Dermatitis: An Update

Our understanding of allergic contact dermatitis mechanisms has progressed over the past decade. Innate immune cells that are involved in the pathogenesis of allergic contact dermatitis include Langerhans cells, dermal dendritic cells, macrophages, mast cells, innate lymphoid cells (ILCs), neutrophils, eosinophils, and basophils. ILCs can be subcategorized as group 1 (natural killer cells; ILC1) in association with Th1, group 2 (ILC2) in association with Th2, and group 3 (lymphoid tissue-inducer cells; ILC3) in association with Th17. Pattern recognition receptors (PRRs) including toll-like receptors (TLRs) and nucleotide-binding oligomerization domain (NOD)-like receptors (NLRs) in innate immune cells recognize damage-associated molecular patterns (DAMPs) and cascade the signal to produce several cytokines and chemokines including tumor necrosis factor (TNF)-α, interferon (IFN)-α, IFN-γ, interleukin (IL)-1β, IL-4, IL-6, IL-12, IL-13, IL-17, IL-18, and IL-23. Here we discuss the recent findings showing the roles of the innate immune system in allergic contact dermatitis during the sensitization and elicitation phases.

Chitosan hydrogel for topical delivery of ebastine loaded solid lipid nanoparticles for alleviation of allergic contact dermatitis

Ebastine, is an antihistamine drug that exerts its effect upon oral administration in humans for the treatment of allergic contact dermatitis (ACD), it also has some systemic side effects like gastric distress, headache, drowsiness, and epistaxis. Moreover, topical corticosteroids are used for treatment of ACD, which causes the human skin to lose its thickness and elasticity. Hence, ebastine-loaded solid lipid nanoparticles (E-SLNs) were prepared and their topical efficacy against allergic contact dermatitis was determined. Compritol 888 ATO and tween 80 were used to prepare E-SLNs by cold dilution of the hot micro-emulsion. E-SLNs were optimized statistically by employing a central composite design using Design-Expert® version 11.0. Optimized E-SLNs showed spherical surface morphology, zeta potential of −15.6 ± 2.4 mV, PDI of 0.256 ± 0.03, and particle sizes of 155.2 ± 1.5 nm and th eentrapment efficiency of ebastine was more than 78%. Nanoparticles were characterized using FT-IR, XRD, and TEM. An E-SLNs loaded hydrogel was prepared using chitosan as a gelling agent and glutaraldehyde as a crosslinker. In vitro drug release studies performed for 24 hours on the E-SLNs dispersion and E-SLNs loaded hydrogel showed a sustained release of maximum 82.9% and 73.7% respectively. In vivo studies were conducted on BALB/c mice to evaluate the topical efficacy of the E-SLNs loaded hydrogel for allergic contact dermatitis. ACD was induced on the ear using picryl chloride solution. After induction, ears were treated daily with the E-SLNs loaded hydrogel for 15 days. Swelling behavior, mast cell count, and histopathological studies of the ear confirmed that the hydrogel alleviated the symptoms of allergic contact dermatitis.

Ebastine exerts its effect upon oral administration in humans for the treatment of allergic contact dermatitis (ACD), but it has some systemic side effects. Hence, ebastine-SLNs loaded hydrogel was prepared to increase topical efficacy of ebastine.

Allergic Contact Dermatitis and Concomitant Dermatologic Diseases: A Retrospective Study

BACKGROUND

Allergic contact dermatitis (ACD) can exist in the setting of other dermatologic conditions. It is known that the treatment of these conditions can cause ACD, increasing both diagnostic and treatment difficulty.

OBJECTIVE

The aim of this study was to determine the frequency of common dermatologic conditions in the setting of ACD and in specific patient populations.

METHODS

A retrospective database study was completed using Truven Health to collect information on patch-tested ACD patients. Demographics and diagnostic information were retrieved. Of those with ACD, the presence of 15 dermatologic diagnoses was investigated. Subanalyses were conducted for each condition, including International Classification of Diseases, 10th Revision code specificity, demographics, and diagnostic information.

RESULTS

A total of 6380 patients (76.83% female) were given a diagnosis of ACD via patch testing. Of those with concomitant disease, those most common include atopic dermatitis (23.98%), urticaria (16.69%), and acne (11.51%). Eight of the concomitant conditions were found to have statistical significance in comparing the average age of ACD diagnosis with the selected diagnoses (α = 0.05).

CONCLUSIONS

Common dermatologic diseases can exist concomitantly with ACD, many of which can be treated by compounds that precipitate or worsen preexisting ACD. The average age of the diagnosis varies from concomitant diagnoses, which can contribute to difficulty in ACD diagnosis and treatment.

Could a Titanium Ulnar Shortening Plate Trigger a Metal Allergy? A Case Report

Background  With the growing use of metallic implants, increased research has focused on metal hypersensitivity. The purpose of this case report is to describe a patient with a suspected metal allergy to a titanium plate and to review the literature behind this controversial topic. Case Description  A 45-year-old woman underwent ulnar shortening osteotomy for ulnocarpal abutment. One year later, the patient continued to have chronic pain at the site of the implant, with negative work-up for infection, hardware loosening, or failure. During hardware removal, intraoperative findings revealed titanium particle wear in the surrounding tissues, and subsequent allergy testing revealed a new diagnosis of nickel allergy. Following hardware removal, the patient had complete resolution of her symptoms at 3 months without any recurrence after 12 months from the date of surgery. Discussion  Metals are the most common cause of allergic contact dermatitis. With the increased use of metallic implants, it is no surprise that metal implant allergies have become a cause for concern. While there are multiple tests to try and diagnose a metal implant allergy, there is no gold standard, and results are often difficult to interpret. Physicians need to be cognizant of metal allergies with there often vague symptoms as we continue to search for more reliable and affordable testing. Clinical Relevance  Metal implant allergies can be difficult to diagnose. It is often a diagnosis of exclusion but requires a heightened sense of awareness in the face of a negative work-up with persistent symptoms.

Cutaneous reactions caused by nitrofurazone

Introduction

Allergic contact dermatitis (ACD) is a form of dermatitis due to type 4 hypersensitivity reaction that occurs when the skin comes into contacts with the topical product. Topical nitrofurazone is a widely used antimicrobial drug in our country which is well known to cause ACD.

Aim

In this study, ACD cases with different clinical features attributed to the use of nitrofurazone were evaluated.

Material and methods

Patients hospitalized in our clinic between 2013 and 2017 with ACD diagnosis due to nitrofurazone were evaluated. The patient age, gender, atopy histories, clinical features, dissemination of the lesions, treatment given were reviewed.

Results

In a 5-year period, 58 cases were identified and their data were analysed. Twelve patients were female (21%), 46 patients were male (79%). Clinical presentations were dyshidrosiform (45%), excoriated papules and plaques (33%), combined (21%), and erythroderma in one patient. The dissemination was generalized in 34 patients, localized in 14 patients, and local spread in 10 patients. The mean hospitalization time was 7 ±3 days, and ranged from 3 to 18 days.

Conclusions

There may be widespread and severe ACD due to the use of nitrofurazone. Topical nitrofurazone should not be applied on damaged skin as sensitization may develop. Patients and physicians should be aware of the ACD risk associated with topical nitrofurazone, which is also commonly used as self-medication, physicians should take a detailed history of the drug use and products containing nitrofurazone should not be used in conditions where skin integrity is not intact, whenever possible.

Job safety analysis and hazard identification for work accident prevention in para rubber wood sawmills in southern Thailand

OBJECTIVE

We utilized job safety analysis (JSA) and hazard identification for work accident prevention in Para rubber wood sawmills, which aimed to investigate occupational health risk exposures and assess the health hazards at sawmills in the Trang Province, located in southern Thailand.

METHODS

We conducted a cross-sectional study which included a walk-through survey, JSA, occupational risk assessment, and environmental samplings from March through September 2015 at four Para rubber wood sawmills.

RESULTS

We identified potential occupational safety and health hazards associated with six main processes, including: 1) logging and cutting, 2) sawing the lumber into sheets, 3) planing and re-arranging, 4) vacuuming and wood preservation, 5) drying and planks re-arranging, and 6) grading, packing, and storing. Working in sawmills was associated with high risk of wood dust and noise exposure, occupational accidents injuring hands and feet, chemicals and fungicide exposure, and injury due to poor ergonomics or repetitive work.

DISCUSSION

Several high-risk areas were identified from JSA and hazard identification of the working processes, especially high wood dust and noise exposure when sawing lumber into sheets and risk of occupational accidents of the hands and feet when struck by lumber. All workers were strongly recommended to use personal protective equipment in any working processes. Exposures should be controlled using local ventilation systems and reducing noise transmission. We recommend that the results from the risk assessment performed in this study be used to create an action plan for reducing occupational health hazards in Para rubber sawmills.

Nickel-Related Intestinal Mucositis in IBS-Like Patients: Laser Doppler Perfusion Imaging and Oral Mucosa Patch Test in Use

Nickel (Ni) is often the trigger of irritable bowel syndrome (IBS)-like gastrointestinal disorders: its ingestion may cause allergic contact mucositis, identifiable by means of oral mucosa patch test (omPT). OmPT effectiveness has been proven, but it is still an operator-dependent method. Laser Doppler perfusion imaging (LDPI) was tested to support omPT in Ni allergic contact mucositis diagnosis. Group A: 22 patients with intestinal/systemic symptoms related to the ingestion of Ni-containing foods. Group B: 12 asymptomatic volunteers. Ni-related symptoms and their severity were tested by a questionnaire. All patients underwent Ni omPT with clinical evaluation at baseline (T0), after 30 min (T1), after 2 h (T2), and after 24-48 h (T3). LDPI was performed to evaluate the mean mucosal perfusion at T0, T1, and T2. Statistical analysis was performed by ANOVA test and Bonferroni multiple-comparison test. All 22 Ni-sensitive patients (group A) presented oral mucosa hyperemia and/or edema at T2. Eight out of the same 22 patients presented a local delayed vesicular reaction at T3 (group A1), unlike the remaining 14 out of 22 patients (group A2). All 12 patients belonging to control group B did not show any alteration. The mean mucosal perfusion calculated with LDPI showed an increase in both subgroups A1 and A2. In group B, no significant perfusion variations were observed. LDPI may support omPT for diagnostic purposes in Ni allergic contact mucositis. This also applies to symptomatic Ni-sensitive patients without aphthous stomatitis after 24-48 h from omPT and that could risk to miss the diagnosis.

Cobalt release and complications resulting from the use of dental prostheses

BACKGROUND

Cobalt release from dental prostheses has been shown to elicit allergic reactions in cobalt-allergic patients. It is therefore important to investigate whether these prostheses are possible sources of sensitization.

OBJECTIVES

To assess (i) cobalt release from dental prostheses and (ii) allergic reactions to components of dental prostheses, and (iii) to investigate the oral mucosa for inflammation 1-5 years after insertion of the prostheses.

METHOD

Clinical oral examination was conducted in 66 patients with 84 dental prostheses. Cobalt release from 84 functional (used) and 32 non-functional (new) prostheses was investigated with the cobalt spot test. Contact allergy was assessed by patch testing. Smear tests for Candida spp. were performed in patients showing signs of inflammation of the oral mucosa. The prostheses were assessed for biological and technical complications.

RESULTS

None of the functional prostheses released cobalt, whereas this was observed in 24 of 32 non-functional prostheses. None of the patients had contact allergy to cobalt. Of the 66 patients, 11 showed signs of inflammation of the oral mucosa, 2 had oral candidiasis, 16 had ill-fitting prostheses, and all had insufficient oral hygiene.

CONCLUSIONS

Dental prostheses released cobalt during the fabrication stages, but not 1-5 years after insertion. No allergic reactions were observed. Signs of inflammation were related to candidiasis, insufficient oral hygiene, and ill-fitting prostheses.

Peripheral blood lymphocyte typing as a useful tool to objectify the oral mucosa patch test in the diagnosis of allergic contact mucositis to nickel

Nickel (Ni) exposure through the intestinal mucosa may cause a hypersensitivity reaction recently defined as allergic contact mucositis (ACM). This condition is identifiable by the oral mucosa patch test (omPT), a qualitative and subjective examination that requires clinical expertise. Our aim was to evaluate if a peripheral blood lymphocyte typing performed before and after the omPT for Ni may be able to objectify this examination for diagnostic purposes. Thirty patients with symptoms referable to the ingestion of Ni-rich foods were subjected to omPT for Ni. Before and after the omPT, each patient underwent blood sampling for the typing of total lymphocytes and their subsets (T, T helper or Th, T cytotoxic or Tc, B, natural killer or NK). Statistical analysis was performed by Student t test and receiver operating characteristic (ROC) curve analysis. According to the omPT outcomes, 18 patients were defined as Ni-sensitive and the remaining 12 as controls. In Ni-sensitive patients, the number of total, T, Th, Tc, and B lymphocytes/μL whole blood increased after the omPT (p<0.0001 for the first three, p=0.0004 and p=0.0001 for the last two lymphocyte types). No omPT-dependent lymphocyte increase was observed in controls. The post/pre omPT cell ratio, especially if calculated for Th lymphocytes, appears to be an effective index for diagnostic purposes (sensitivity=100%, specificity=83.3%, Youden index=0.833, area under curve (AUC)=0.926, p<0.0001). In conclusion, the peripheral blood lymphocyte typing with calculation of post/pre omPT cell ratio has the potential to support the omPT in diagnosing ACM, with the advantage of providing quantitative and objective data.

Immunological characterization of the allergic contact mucositis related to the ingestion of nickel-rich foods

BACKGROUND

The ingestion of nickel (Ni)-rich foods may result in allergic contact mucositis (ACM), a not yet well defined condition identifiable by oral mucosa patch test (omPT). Our aim was to characterize immunologically the ACM taking advantage from the allergen exposure that occurs during the omPT for Ni.

METHODS

Thirty-seven symptomatic patients underwent to omPT for Ni. Before and after omPT, serum and urine Ni concentrations were determined by mass spectrometry, the white blood cells were counted by hemochromocytometric assay, the peripheral lymphocyte typing was carried out by flow cytometry, total IgE and cytokine serum concentrations were measured by immunoenzymatic assays. The local lymphocyte typing was performed by immunohistochemistry only after omPT.

RESULTS

According to the omPT outcomes, 25 patients were defined as Ni-sensitive and the remaining 12 as controls. After omPT, serum and urine Ni concentrations increased significantly in all patients, while a significant increment of circulating lymphocytes and neutrophils was highlighted, respectively, in Ni-sensitive and control patients. Consistently, the Th and Tc circulating lymphocytes, as well as the Th/Tc ratio increased significantly in Ni-sensitive patients after omPT. No noteworthy increment in serum concentrations of total IgE and selected cytokines was observed in any patient after omPT. The presence of CD3+, CD4+, and CD8+ cells was highlighted on the oral mucosa biopsy samples taken from Ni-sensitive patients after omPT.

CONCLUSIONS

In patients with ACM, a local adaptive response with increased lymphocyte trafficking appears to be the most likely mechanism of reaction to Ni administered with the omPT.

Pattern of patch test reactivity among patients with clinical diagnosis of contact dermatitis: a hospital-based study

BACKGROUND AND OBJECTIVES

Contact allergy is associated with a significant morbidity all over the world. This study was performed to investigate the pattern of sensitization by contact allergens in the local population.

DESIGN AND SETTING

Retrospective study to investigate patch test reactivity among patients with clinical diagnosis of contact dermatitis who were referred to the allergy clinic at the King Khalid University Hospital, Riyadh, between April 2008 and March 2010.

PATIENTS AND METHODS

Of the 196 patients referred to the allergy clinic over the 2-year period, 91 (46.4%) patients reacted to one or more patch test allergens, and these patients were included in this study. The study group included 82 (91.1%) of Saudi nationality and 9 (8.9%) patients of other nationalities. The patch test was performed using the T.R.U.E TEST, containing 24 allergens/allergen mixes.

RESULTS

Of the 91 cases who reacted positively to one or more allergens, 67 (73.6%) were females with a mean age of 37 (8.3 years) and 24 (26.4%) were males with a mean age of 34 (11.6 years). Thirty-three (36.2%) patients reacted to nickel sulfate, 14 (15.3%) to p-phenylenediamine, 13 (14.2%) to p-tert-butylphenol-formaldehyde resin, 13 (14.2%) to thimerosal, and 9 (9.8%) to colophony. Reactivity against the rest of the allergens was not remarkable. A significantly higher percentage of females reacted to nickel sulfate (84.8% vs 15.2% in males;P=.0001), p-tert-butylphenol-formaldehyde resin (92.3% vs 7.7%; P=.0001), and thimerosal (76.9% vs 23.1%;P=.03).

CONCLUSIONS

Patch test reactivity to nickel sulfate was high. The pattern of contact allergy observed in this study indicates the need for large-scale investigations to identify local allergens responsible for contact allergy and for formulation of policies directed towards avoidance of exposure.

Dermatophytid in tinea capitis: rarely reported common phenomenon with clinical implications

Tinea capitis may be associated with a dermatophytid, which appears as a disseminated eczematous eruption. This phenomenon may occur before or after initiation of systemic antifungal drug therapy and is not an indication for stopping medication. We present here a series of cases that involve 5 children with tinea capitis who developed a dermatophytid before or during the course of their management. In each child, the eruption resolved despite continuation of oral antifungal therapy. Our experience suggests that dermatophytid secondary to tinea capitis is much more common than reported. Furthermore, parents and clinicians frequently mistake dermatophytid for drug allergy. Recognition of this phenomenon, distinction of dermatophytid from drug allergy, and continuation of systemic treatment is essential for clearing the infection and dermatophytid.

Oral mucosa patch test: a new tool to recognize and study the adverse effects of dietary nickel exposure

On contact with the skin, nickel may cause allergic contact dermatitis, which can be diagnosed by an epicutaneous patch test. Nickel exposure via the intestinal mucosa can induce diarrhea, abdominal pain, and swelling. The aim of the present study was to investigate the relationship between these symptoms and nickel intake by means of a novel oral mucosa patch test. Eighty-six patients with intestinal symptoms related to ingestion of nickel-containing foods were submitted to epicutaneous and oral mucosa patch tests for nickel. All patients with positive oral mucosa patch test results were subject to a low-nickel diet and monitored over time. Skin lesions were observed in 33 out of 86 (38.4%) patients evaluated by the epicutaneous patch test. Mucosal lesions were seen in 53 out of 86 (61.6%) patients given the oral mucosa patch test. After 2 months of a low-nickel diet, 52 out of 53 (98.1%) patients showed an improvement of their symptoms. There is a significant correlation between response time of the oral mucosa patch test and the latency of symptoms after ingestion of nickel-containing foods. Consequently, the oral mucosa patch test can be used to recognize and study the adverse effects of dietary nickel exposure that could be defined as allergic contact mucositis. A low-nickel diet is also shown to be an effective treatment for this condition.

Allergic skin disease: major highlights and recent advances

AD, urticaria, and ACD account for a large percentage of the skin disorders that present at medical offices and emergency departments. With a high degree of morbidity, these diseases can be extremely difficult to manage. Consequently, these diseases continue to be the focus of much of the new research in the field. Recent studies have furthered the understanding of the complex relationship between immune and nonimmune factors in the pathogenesis of these disorders. This research has quickly led to the development of new treatment modalities and protocols for patient care, especially for AD. However, further discovery will be necessary to optimize the management of these often-vexing conditions.

Root canal treatment on a patient with zinc oxide allergy: a case report

AIM

To describe successful root canal treatment of a patient with a true zinc oxide allergy and to discuss allergic reactions to dental materials.

SUMMARY

Dental materials have been reported as aetiologic agents for both local and systemic allergic reactions. It is essential for the oral healthcare provider to recognize the clinical symptoms associated with allergic reactions and to modify dental treatment, if necessary, to prevent these reactions from occurring. This article describes an unusual case of a patient with an allergy to zinc oxide. To our knowledge, this is the first case of successful root canal treatment of a patient with confirmed zinc oxide allergy to be reported in the dental literature.

KEY LEARNING POINTS

Medical and dental histories must be evaluated to prevent medical complications secondary to dental treatment. Any patient suspected of having an allergy to dental materials should be referred to a healthcare professional capable of performing and interpreting allergy tests prior to dental treatment.