The British standard series of contact dermatitis allergens: validation in clinical practice and value for clinical governance

Imidazolidinyl Urea

The Expert Panel for Cosmetic Ingredient Safety reviewed updated information that has become available since their original assessment from 1980, along with updated information regarding product types, and frequency and concentrations of use, and reaffirmed their original conclusion that Imidazolidinyl Urea is safe as a cosmetic ingredient in the practices of use and concentration as described in this report.

The sesquiterpene lactone mix: A review of past, present and future aspects

The sesquiterpene lactones (SLs) are secondary plant metabolites, which are widespread in the Compositae/Asteraceae plant family. The first SLs were detected more than 100 years ago, and allergic contact dermatitis from Compositae has been reported since the beginning of the 1900s, but it was not until the late 1960s and early 1970s that a collaboration between dermatologists, chemists and botanists led to the detection of SLs as the main allergens of Compositae plants. In the 1980s, the SL mix, consisting of equimolar amounts of alantolactone, costunolide and dehydrocostus lactone, was developed as a screening agent for Compositae sensitisation. Today, after inclusion of SL mix in the baseline series, the mean prevalence of reactions in Europe is around 1%, and in North America 0.8%. In countries outside Europe and North America, the prevalence ranges between 0% and 10.7%. The detection rate of SL mix is lower than that of some plant extracts, and ideally, SL mix should be supplemented with a mix of SLs from locally prevalent allergenic plants. The prevalence of positive reactions to SL mix suggests continued baseline testing in most European countries, North America, New Zealand, Australia and probably some Chinese centres.

Analysis of patch testing results in patients with contact dermatitis in Istanbul, Turkey, from 2012 to 2022

BACKGROUND

Allergens responsible for allergic contact dermatitis (ACD) differ between populations. They can even change over the years with the effect of environmental factors.

AIMS

To evaluate the results of patch testing performed in our center.

METHODS

In this study, the thin-layer rapid-use epicutaneous (T.R.U.E.) test results of patients with a diagnosis of ACD between 2012 and 2022 were retrospectively evaluated.

RESULTS

In 431 (42.5%) of the total 1012 patients, a positive reaction to at least one allergen was detected in the patch test. Allergen positivity was most detected for nickel sulphate (16.8%), gold sodium thiosulfate (GST) (6.9%), thimerosal (4.2%), fragrance mix (3.4%), carba mix (3.2%), and cobalt dichloride (2.9%). Nickel sulfate and GST sensitivity was found to be significantly higher in women, fragrance mix sensitivity in men, thimerosal sensitivity in individuals aged under 40 years, colophony and balsam of Peru sensitivity in head and neck dermatitis, and carba mix and thiuram mix sensitivity in atopic individuals.

CONCLUSIONS

This study presents comprehensive data from Turkey concerning the sensitivity frequencies for allergens included in the T.R.U.E. test.

Artificial Intelligence That Predicts Sensitizing Potential of Cosmetic Ingredients with Accuracy Comparable to Animal and In Vitro Tests-How Does the Infotechnomics Compare to Other "Omics" in the Cosmetics Safety Assessment?

The aim of the current study was to develop an in silico model to predict the sensitizing potential of cosmetic ingredients based on their physicochemical characteristics and to compare the predictions with historical animal data and results from "omics"-based in vitro studies. An in silico model was developed with the use of WEKA machine learning software fed with physicochemical and structural descriptors of haptens and trained with data from published epidemiological studies compiled into estimated odds ratio (eOR) and estimated attributable risk (eAR) indices. The outcome classification was compared to the results of animal studies and in vitro tests. Of all the models tested, the best results were obtained for the Naive Bayes classifier trained with 24 physicochemical descriptors and eAR, which yielded an accuracy of 86%, sensitivity of 80%, and specificity of 90%. This model was subsequently used to predict the sensitizing potential of 15 emerging and less-studied haptens, of which 7 were classified as sensitizers: cyclamen aldehyde, N,N-dimethylacrylamide, dimethylthiocarbamyl benzothiazole sulphide, geraniol hydroperoxide, isobornyl acrylate, neral, and prenyl caffeate. The best-performing model (NaiveBayes eAR, 24 parameters), along with an alternative model based on eOR (Random Comittee eOR, 17 parameters), are available for further tests by interested readers. In conclusion, the proposed infotechnomics approach allows for a prediction of the sensitizing potential of cosmetic ingredients (and possibly also other haptens) with accuracy comparable to historical animal tests and in vitro tests used nowadays. In silico models consume little resources, are free of ethical concerns, and can provide results for multiple chemicals almost instantly; therefore, the proposed approach seems useful in the safety assessment of cosmetics.

Frequency of Allergenic Ingredients in Antifungal Creams

BACKGROUND

Allergic contact dermatitis (ACD) may occur secondary to topical antifungals containing potential allergens in their vehicles. Variation of allergenic ingredients among commonly used antifungal creams (AFCs) has not been well characterized.

OBJECTIVE

The study goal was to assess the frequency of allergenic ingredients in 4 commonly used topical AFCs.

METHODS

Topical AFCs (clotrimazole, ketoconazole, miconazole, and terbinafine) were selected, and the ingredient lists for these products were obtained from the US Food and Drug Administration's Online Label Repository via a proprietary name search. A systematic literature review was performed using the ingredient name on MEDLINE (PubMed) database to identify reports of ACD confirmed by patch testing.

RESULTS

Of the 20 ingredients analyzed, 6 had frequent allergenic potential. Propylene glycol was the most common cause of ACD identified in the literature and is an ingredient in ketoconazole 2% and miconazole nitrate 2%. Ketoconazole 2% and miconazole nitrate 2% creams contained the highest number of potential allergens (n = 3) among the 4 creams analyzed.

CONCLUSIONS

Of the 4 creams, terbinafine hydrochloride 1% and clotrimazole 1% contained the least number of potential allergenic ingredients. Awareness of the allergenic potential of commonly used AFCs may help health care providers when evaluating patients with ACD.

Decreasing Rates of Neomycin Sensitization in Western Canada

Background:

Neomycin contact sensitization rates in North America range from 7% to 13%, whereas in Europe they average approximately 1.9%.

Objectives:

Given that topical neomycin products are no longer readily available in Canada, the aim of this study was to examine what influence this may have had on neomycin sensitization rates in the 3 western provinces.

Methods:

On the basis of an observation originally communicated by L. M. Parsons and C. Zhang of the University of Calgary, which suggested significantly reduced rates of neomycin sensitization in Calgary, Alberta, Canada, a multicenter study of patch test results from 5690 patient charts was undertaken. Data from 3 other western Canadian Universities (the University of Saskatchewan, the University of Alberta, and the University of British Colombia) were analyzed. Data were available from 2001 to 2013 for the University of Saskatchewan (except 2006), whereas the University of Alberta and the University of British Columbia had data from 2009 to 2013. Descriptive statistics, trend analysis, and risk estimates were determined using SPSS version 20.

Results:

Sensitization rates for neomycin have decreased in western Canada and are now similar to those of Europe.

Conclusions:

This trend is likely influenced by the reduced availability of over-the-counter and prescription neomycin products in Canada.

Contact dermatitis: a practice parameter-update 2015

This parameter was developed by the Joint Task Force on Practice Parameters, which represents the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma & Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Contact Dermatitis: A Practice Parameter-Update 2015." This is a complete and comprehensive document at the current time. The medical environment is changing and not all recommendations will be appropriate or applicable to all patients. Because this document incorporated the efforts of many participants, no single individual, including members serving on the Joint Task Force, are authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information or interpretation of this practice parameter by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by the pharmaceutical industry in drug development or promotion. Previously published practice parameters of the Joint Task Force on Practice Parameters for Allergy & Immunology are available at http://www.JCAAI.org or http://www.allergyparameters.org.

Surveillance of contact allergies: methods and results of the Information Network of Departments of Dermatology (IVDK)

Contact allergy (CA) surveillance networks provide information to a multitude of stakeholders, which is indispensable for evidence-based decision-making in the field of prevention. Methods and results of the German surveillance system on CA are reviewed and discussed with reference to other systems. The German network structure comprises 56 departments of dermatology and includes all patients who are patch-tested for suspected CA. Data analysis considers the results of patch testing and further pertinent information for each patient. Following aspects are addressed: (i) the description of the clinical population, (ii) evaluation of patch test reactions, (iii) relationship between patch test results and population characteristics. Trend analyses on chromate (decreasing), epoxy resin (increasing) and nickel (heterogeneous) served as examples for surveillance system analyses, with the identification of sentinel events, as well as proof of success or failure of prevention. In addition, external data sources can be used such as sales data of patch test preparations to estimate frequencies of sensitization on a population level. National prescription data of drugs and statistics of labelling of preservatives on cosmetics can be included, the latter two approaches allowing for risk estimates conferred by specific allergens.

Classification of skin sensitizing substances: a comparison between approaches used by the DFG-MAK Commission and the European Union legislation

A systematic classification of substances (or mixtures of substances) with regard to various toxicological endpoints is a prerequisite for the implementation of occupational safety strategies. As its principal task the "Commission for the Investigation of Health Hazards of Chemical Compounds in the Work Area" of the "Deutsche Forschungsgemeinschaft" (DFG-MAK Commission) derives and recommends maximum workplace concentrations and biological tolerance values (MAK and BAT values) based exclusively on scientific arguments. Several endpoints are evaluated separately in detail, e.g. carcinogenicity, risks during pregnancy, germ cell mutagenicity or contribution to systemic toxicity after cutaneous absorption. Skin- and airway sensitization is also considered; the present paper focuses on these two endpoints.

Absorption of nickel, chromium, and iron by the root surface of primary molars covered with stainless steel crowns

Objective. The purpose of this study was to analyze the absorption of metal ions released from stainless steel crowns by root surface of primary molars. Study Design. Laboratory research: The study included 34 primary molars, exfoliated or extracted during routine dental treatment. 17 molars were covered with stainless-steel crowns for more than two years and compared to 17 intact primary molars. Chemical content of the mesial or distal root surface, 1 mm apically to the crown or the cemento-enamel junction (CEJ), was analyzed. An energy dispersive X-ray spectrometer (EDS) was used for chemical analysis. Results. Higher amounts of nickel, chromium, and iron (5-6 times) were found in the cementum of molars covered with stainless-steel crowns compared to intact molars. The differences between groups were highly significant (P < .001). Significance. Stainless-steel crowns release nickel, chromium, and iron in oral environment, and the ions are absorbed by the primary molars roots. The additional burden of allergenic metals should be reduced if possible.

Frequency of sensitization to common allergens: comparison between Europe and the USA

BACKGROUND

Previously, contact allergy to formaldehyde and quaternium-15 was found to be more prevalent in the United States than in Europe. No such data have been assessed for other contact allergens.

OBJECTIVE

Determine any differences in frequencies of sensitization to contact allergens in the United States and Europe.

METHODS

Literature study. Comparison of reported frequencies of sensitization to contact allergens routinely tested both in the United States and Europe in recent, large, multicentre studies. Because of the heterogeneity of studies and background parameters, statistical evaluation was not attempted.

RESULTS

Major differences were found only for neomycin (USA 10.0-11.8%, mean 11.4%; Europe 1.2-5.4%, mean 2.6%). Most allergens had somewhat higher prevalence in the United States, with rates versus Europe ranging from 1.3 to 1.9.

CONCLUSIONS

Contact allergy to neomycin is much more prevalent in the United States. Stricter selection of patients for patch testing in United States tertiary referral centres may result in 50% more positive reactions compared to European studies.

Epidemiological data on consumer allergy to p-phenylenediamine

Many women and men now dye their hair. p-Phenylenediamine (PPD) is a frequent and important component of permanent hair dye products; exposure to it may cause allergic contact sensitization, acute dermatitis, and severe facial oedema. To increase our understanding of PPD allergy, we reviewed published literature containing PPD patch test data from dermatitis patients and individuals in the general population. This was performed to estimate the median prevalence and the weighted average of PPD sensitization and thereby assess the burden of PPD-containing hair care products on health. Literature was examined using PubMed-MEDLINE, Biosis, and Science Citation Index. The median prevalence among dermatitis patients was 4.3% in Asia, 4% in Europe, and 6.2% in North America. A widespread increase in the prevalence of PPD sensitization was observed among Asian dermatitis patients. In Europe, a decrease in the 1970s was replaced by a plateau with steady, high prevalences ranging between 2% and 6%. The prevalence remained high in North America, although a decreasing tendency was observed. Contact allergy to PPD is an important health issue for both women and men. More stringent regulation and enforcement are required as public health measures to reduce the burden of disease that exposure to PPD has brought to populations.

Contact allergies in haemodialysis patients: a prospective study of 75 patients

BACKGROUND

Haemodialysis exposes patients to many potentially sensitizing allergens.

OBJECTIVES

The primary objective of this study was to evaluate the prevalence of delayed hypersensitivity in a population of haemodialysis patients. Secondary objectives were to identify the possible risk factors for contact sensitization and to propose a series of skin tests adapted to haemodialysis patients.

METHODS

A prospective monocentric study was carried out in a nonselected population of haemodialysis patients. For each patient, medical history of atopy and allergic contact dermatitis, ongoing treatments (including topical ones), presence of eczema at the site of vascular access for haemodialysis were recorded. Allergological investigation included delayed hypersensitivity tests (European Environmental and Contact Dermatitis Research Group battery, tests GERDA, additional list and a battery of antiseptics and other dialysis-specific allergens) and latex skin prick test.

RESULTS

Seventy-five patients (41 men, 34 women, mean age of 65 years old), with a mean 3.8 years under dialysis, were included. Nineteen patients (25%) had at least one positive skin test and 13 (17%) a positive patch test to at least one allergen relative to dialysis process including eight tests to lidocaine-prilocaine cream and three to povidone-iodine. Tests results seemed clinically relevant since nine patients had localized pruritus at the fistula site and six patients active eczema around it.

CONCLUSION

Contact sensitizations are frequent in haemodialysis patients and are linked to vascular access conditioning especially the use of lidocaine-prilocaine cream. Designing a specific test battery could help to diagnose the potential allergens and subsequently to give advice to avoid contact with sensitizing agents.

Whither... the future for contact dermatitis? A report from the 2007 International Review of Current Problems in Contact Dermatitis

In our report we summarize presentations made at the International Review of Current Problems in Contact Dermatitis meeting which took place at the St John's Institute of Dermatology, London, on 1 June 2007, and which brought together over 100 dermatologists from the U.K., continental Europe and the U.S.A. During this small and informal meeting, the state-of-the art lectures on various aspects of contact dermatitis were followed by energetic discussions.

The European Surveillance System of Contact Allergies (ESSCA): results of patch testing the standard series, 2004

BACKGROUND

The European Surveillance System on Contact Allergies (ESSCA) began in 2001 as project funded by a European Union grant to monitor and evaluate contact sensitization (CS) based on clinical data collected by participating European dermatology departments.

OBJECTIVES

ESSCA aims to detect trends in CS in an international patch test population, monitoring the frequency of CS to (standard series) allergens, evaluating the effectiveness of intervention (e.g. governmental regulations) and improving standardization of the patch test procedure on an international level.

METHODS

In 2004, 31 ESSCA dermatology departments in 11 European countries collected patch test results and medical histories of patients tested with the European Standard Series (ESS) or a local standard allergen series using the multilingual Winalldat/ESSCA database, the German Winalldat/Information Network of Departments of Dermatology (IVDK) database or a locally created database including the items of the ESSCA 'minimal data set'. Data were sent to the ESSCA data centre where they were imported, pooled, examined for quality and subsequently analysed.

RESULTS

The departments patch tested 11 643 patients with a standard series, and 44% of the patients tested positive to one or more substances of the ESS. Nickel sulphate, the fragrance mix, Myroxylon pereirae resin, cobalt chloride, potassium dichromate, methyldibromoglutaronitrile and paraphenylenediamine are (still) the most important allergens detected. Several additional substances tested on consecutive patients in some clinics were also examined. Among these allergens, propolis and Compositae mix had a relatively high CS prevalence.

CONCLUSIONS

The expanding ESSCA network continues to provide up-to-date information regarding the pattern of CS diagnosed in participating departments across Europe.

Contact sensitivity to preservatives in the UK, 2004?2005: results of multicentre study

Preservative sensitivity in the UK was last assessed in 2000. Given the changes in preservative usage, we have re-evaluated our patch test data in order to detect any changes in the trend of sensitization. The results of patch testing using the extended British Contact Dermatitis Society Standard series were collected from 9 dermatology centres in the UK. Positive reactions to each of 10 preservative allergens were captured together with the MOAHFLA indices for each centre. In total, 6958 patients were tested during the period 2004-2005. The current data were compared with previously published data. Formaldehyde and methylchloroisothiazolinone/methyl-isothiazolinone have the highest positivity rates at 2.0% and chloroxylenol the lowest at 0.2%. Parabens mix has the highest irritancy rate. Compared with the UK data in 2000, the positivity rate of imidazolidinyl urea (0.02 < P < 0.05) has significantly increased and that of methyldibromo glutaronitrile has significantly reduced (P < 0.001).

The effects of nickel and chromium on human keratinocytes: Differences in viability, cell associated metal and IL-1α release

This study was carried out to assess the effects of chromium and nickel upon isolated keratinocytes as an in vitro model of human skin. Keratinocytes were isolated from healthy volunteer skin samples of unknown metal sensitivity (n=10) and were compared with cells from patient biopsies of known metal sensitivity (n=7). Cells were dosed with a concentration range of nickel and chromium (0-10,000 microM) and cellular mitochondrial activity, viability, metal uptake and cytokine release were measured. Responses of primary versus passaged keratinocytes were also compared. Toxicity data from primary and passaged keratinocytes was statistically analysed by the non-linear Hill Plot model. Results showed that hexavalent chromium was significantly more cytotoxic, associated more with keratinocytes and induced a dose dependant release of IL-1alpha compared to nickel. Significant differences were observed between primary and passaged keratinocytes with regard to the toxicity of chromium and nickel and variation of response. No differences were observed in the cytotoxicity or cytokine release induced by chromium or nickel for the known sensitised biopsy patient samples (n=4) compared to patch test negative controls (n=3). The results from this study suggest human keratinocytes in vitro respond very differently to chromium and nickel.

Primin in the European standard patch test series for 20 years

Primin was included in the European standard series (ESS) in 1984. In 2000, a primin-free variant of Primula obconica, the main source of contact allergy to primin, was introduced in the market. The aim of this study was to analyse the trends of primin allergy in 13 986 consecutively patch-tested eczema patients over a 20-year period from 1985 to 2004. 151 patients gave a positive patch test to primin. The majority were women, in two-third of patients the patch test was relevant and most presented with hand eczema. Only few of the cases (4.7%) were occupational. A significant decline of contact allergy to primin was seen (P < 0.001) over the years affecting all age groups. The frequency was 0.5% during 2000-2004. Contact allergy has been rare since 2000. The low frequency of positive patch test to primin does not support inclusion in the ESS in our region.

Updates from the British Association of Dermatologists 86th Annual Meeting, 4?7 July 2006, Manchester, U.K

Here we provide a synopsis of the main clinical and research advances in clinical, epidemiological and biological dermatology that were presented at the meeting of the British Association of Dermatologists (BAD) held during 4-7 July 2006, in Manchester, U.K. Only the more important advances or summaries of findings are mentioned. The meeting was held at the Manchester International Conference Centre (Fig. 1). The annual dinner was held at Manchester Town Hall, in the Great Hall decorated with magnificent murals by Ford Madox Brown, with Dr Susan Burge as host.

Standard patch test results in patients with contact dermatitis in Israel: age and sex differences

Previous studies have shown that the prevalence of specific allergens varies by geographic area, population, age and sex. The objective of the present study was to determine the relative frequency of positive reactions to different sensitizers in Israeli patients with clinically suspected contact dermatitis (CD) and to identify possible sex and age differences. A total of 943 consecutive patients were tested for CD using the European standard patch test series. The most frequent allergen was nickel sulfate followed by potassium dichromate and fragrance mix. Positive reactions to nickel sulfate were more common among women, especially those in the younger age group (younger than 40 years). Positive reactions to balsam of Peru were more common among men, especially those in the older age group (40 years or older). This study presents the result of the standard patch test in Israel with stratification according to age and sex. The findings of the present study, combined with reports on geographic/population differences in the prevalence of specific allergens in CD, indicate the need for further investigations to identify prominent local allergens for better adaptation of the standard patch test to local needs.

Nickel, cobalt, chromium, palladium and gold induce a mixed Th1- and Th2-type cytokine response in vitro in subjects with contact allergy to the respective metals

Nickel (Ni), the main cause of contact allergy to metals, induces in vitro production of both Th1- and Th2-type cytokines in peripheral blood mononuclear cells (PBMC) from allergic subjects. Because the knowledge of the cellular immune response to other metals involved in contact allergy has been limited, we investigated the cytokine profile induced by Ni, cobalt (Co), chromium (Cr), palladium (Pd) and gold (Au) in PBMC from patients with patch test reactivity to the respective metals. PBMC from patients with patch test reactivity to Ni, Co, Cr, Au and/or Pd (n = 31) and non-allergic controls (n = 5) were stimulated in vitro with corresponding metal salts. Th1- [interleukin (IL)-2 and interferon (IFN)-gamma] and Th2- (IL-4 and IL-13) type cytokine responses were measured by enzyme-linked immunospot (ELISpot) and/or enzyme-linked immunosorbent assay (ELISA). All metals induced a mixed Th1- and Th2-type cytokine production in PBMC from individual patients with patch test reactivity to the corresponding metal, but not in control PBMC. Significantly higher responses in the patient versus controls were found for Cr (IL-2 and IL-13), Pd (IL-2 and IL-4), Au (IL-13 and IFN-gamma) (all P < 0.05) and Ni (all four cytokines; P < 0.01) but not Co. Overall, 71% (37/52) and 89% (81/91) of the positive and negative patch test reactivities to metals, respectively, were matched by the in vitro reactivity. In conclusion, our data suggest that sensitization to Co, Cr, Pd and Au results in a cellular immune response of a character similar to the mixed Th1- and Th2-type cytokine profile shown previously to be induced by Ni.

Allergic contact dermatitis to chloroxylenol

Chloroxylenol, also known as p-chloro-m-xylenol (PCMX), is a compound that has been used as a preservative in cosmetics and as an active agent in antimicrobial soaps. We present two patients with allergic contact dermatitis from PCMX, confirmed by positive (+++) patch-test reactions at 48 and 72 hours, identification of PCMX in a soap and in a hand cream used by the patients, and improvement following withdrawal of the incriminating products. The mechanism of action, structure, antimicrobial activity, and dangers of PCMX are reviewed.

European Standard Series patch test results from a contact dermatitis clinic in Israel during the 7-year period from 1998 to 2004

The results of a 7-year retrospective study (1998-2004) from patch testing with the European Standard Series (ESS) establishing the frequency of sensitization in a contact dermatitis clinic in Israel are presented. 23 allergens were patch tested on 2156 patients, 1462 females (67.8%) and 694 males (32.2%). Atopy and asthma were present in 21.9% of the patients. One or more allergic reactions were observed in 937 patients (43.5%). The highest yield of patch test positives from the 1076 positive reactions were obtained from nickel sulfate (13.9%), fragrance mix (7.1%), potassium dichromate (3.8%), Balsam of Peru (3.6%), CL+Me-isothiazolinone (3.4%) and cobalt chloride (3.4%). Allergens which produced the least amount of positive results were primin and clioquinol. Allergic contact dermatitis (ACD) was established in 32.8%, whereas occupationally related allergic (8.0) and irritant contact dermatitis (5.6%) affected a total of 13.6% of the cases studied. The most common clinical forms of dermatitis were chronic dermatitis (47.7%) followed by acute dermatitis (22.8%), and lichenification and hyperkeratosis (7.9%). The hands (30.7%), face and neck (23.9%) and extremities (11.3%) were the most frequently affected areas. Four allergens in our study differed from the top 10 allergens in Europe namely: Cl+Me-isothiazolinone, formaldehyde, 4-tert-butylphenol formaldehyde resin and sesquiterpene lactone mix reflecting an existing difference in environmental exposure. Our study is the first to provide data on the frequency of sensitization and important allergens in the aetiology of ACD in Israel. In spite of the existing differences with Europe, we conclude that ESS is an appropriate screening system for the diagnosis of ACD in Israel.