Whilst Rome Burns: The Epidemic of Contact Allergy to Methylisothiazolinone

Review - Expert Opinion on Antibiotics and Antibiotic Resistance in Dermatology

INTRODUCTION

Antibiotic resistance has become a serious, severe problem worldwide. This issue does not only relate to the use of systemic antibiotics but to topical ones as well, like systemic therapies and local treatment of skin and mucosal infections. Antiseptics, an alternative to the topical treatment with antibiotics of wounds and some inflammatory dermatological conditions, tend to be microbicidal and have a broader spectrum of antimicrobial activity than antibiotics. Among these, polyhexanide (PHMB) allows for the control of the infection while avoiding the development of resistance.

OBJECTIVES

Recommendations on the rules of good clinical practice for the management of small wounds, burns and post-traumatic ulcerative wounds, impetigo or folliculitis in the initial stages, and acne.

METHODS

Literature review on the principal topical therapies for small wounds, injuries, impetigo, folliculitis, and acne and a proposal of innovative, highly-tolerated treatments.

RESULTS AND CONCLUSIONS

Given the abuse of topical antibiotics in dermatology, for the treatment of small wounds, injuries, localized folliculitis, impetigo, and acne, the use of alternative topical treatments like polyhexanide and Rigenase® is recommended.

Current frequency of contact allergy to isothiazolinones (methyl-, benz- and octylisothiazolinone) across Europe

BACKGROUND

The use of methylisothiazolinone (MI) as a preservative in cosmetic products caused an alarming increase in MI contact allergy across Europe in the 2010s. This was followed by regulations of use with a total ban on leave-on (implemented in 2017) and reduced use concentrations in rinse-off cosmetics (2018).

OBJECTIVE

To follow-up on the prevalence of contact allergy to MI and the related benzisothiazolinone (BIT) and octylisothiazolinone (OIT) in consecutively patch-tested patients in Europe.

METHODS

A cross-sectional audit following the design of two previous audits on MI contact allergy from 1 May 2022 to 31 October 2022 included all patients patch tested with the European baseline series, including or supplemented with MI, BIT and OIT across 10 departments in eight European countries.

RESULTS

A total of 2554 patients were consecutively patch tested with the three isothiazolinones during the study period. The prevalence of MI and BIT contact allergy was 2.9% (95% confidence interval [CI]: 2.3%-3.7%; range 1.1%-5.8%) and 3.1% (95% CI: 2.4%-3.9%; range 0.0%-6.6%), respectively; that of OIT was 0.7% (95% CI: 0.4%-1.1%; range 0%-3.2%). Rinse-off cosmetic (73.3%) and leave-on cosmetic products (13.3%) were still associated with eliciting allergic contact dermatitis to MI.

CONCLUSION

We confirmed a positive impact of regulatory measures on the prevalence of MI contact allergy in Europe, which halved compared to 2015. However, our data suggest that consumers may still be exposed to older cosmetic products containing MI. BIT has superseded MI in causing contact allergy, despite not being allowed for use in cosmetic products.

The epidemic of contact allergy to methylisothiazolinone-An analysis of Danish consecutive patients patch tested between 2005 and 2019

BACKGROUND

In 2005, methylisothiazolinone (MI) was allowed as a stand-alone preservative in cosmetics. This resulted in an epidemic of allergic contact dermatitis to MI, mainly affecting women exposed to leave-on cosmetics. Consequently, a regulation of Annex V in the European Union in 2017 banned the use of MI in leave-on cosmetics and reduced the allowed concentration in rinse-off products.

OBJECTIVE

To analyze the temporal trends in contact allergy to MI in Danish patients in relation to key events including European regulations over time.

METHODS

A retrospective study of consecutive patients patch tested with methylisothiazolinone from 2005 to 2019. Demographics and clinical characteristics in terms of MOAHLFA (male, occupational, atopic dermatitis, hand dermatitis, leg dermatitis, facial dermatitis and age >40 years), sources of exposure, and clinical relevance were analyzed in relation to key historical events.

RESULTS

Three hundred eighty of 12 494 patients (3.0%, 95CI: 2.7-3.4%) tested from 2005 to 2019 were sensitized to MI. An increasing trend in the prevalence of MI contact allergy from 2005 to 2019 (P < .01) was observed, although a decline in the absolute number of patch-test positive patients was seen from 2013 and onward. A reduction in leave-on cosmetics as a source of exposure was observed following the legislative ban in 2017, from 24.8% from in 2010 to 2013 to 6.2% in 2017 to 2019 (P < .01).

CONCLUSION

The epidemic of MI contact allergy is declining in absolute terms, although the prevalence in the patch-tested population has not returned to its pre-epidemic levels. The legislative regulation of MI in 2017 has been effective in terms of leave-on cosmetics as a source of exposure in MI allergic patients. The process of post-marketing risk assessment of contact allergens in the European Union needs improvement.

Isothiazolinones Quantification in Shampoo Matrices: A Matter of Method Optimization or Stability Driven by Interactions?

Methylisothiazolinone (MI) is one of the most used preservatives in shampoos and also one of the most effective. A preservative mixture known as Kathon™ CG is commercially available. It contains 5-chloro-2-methyl-4-isothiazolin-3-one (CMI) and 2-methyl-4-isothiazolin-3-one (MI) (3:1) and stabilizers. The aim of this study is to evaluate the influence of formulation factors in the quantification and stability of isothiazolinones in shampoos. Two shampoo bases containing Kathon™ CG as a preservative were prepared. Some ingredients that are at risk of interfering with the preservative stability were added to these formulations. The preservative was quantified by HPLC-DAD (High-performance liquid chromatography with a diode-array detector) after preparation of the formulation and after storage at room temperature and at 40 °C. The addition of magnesium silicate proved to be essential for the breakdown of the interaction between the matrix and the analytes in the extraction procedure. The content of CMI/MI decreased right after preparation indicating that immediate interactions between CMI/MI and the ingredients may have occurred after preparation resulting in a decrease in the preservative concentration. Detrimental interactions between the ingredients, regarding the stability of the isothiazolinones were detected immediately after preparation and over time resulting in the reduction of CMI/MI concentration in these cosmetic shampoos.

Amended Safety Assessment of Methylisothiazolinone as Used in Cosmetics

The Cosmetic Ingredient Review Expert Panel (Panel) reviewed the safety of methylisothiazolinone (MI), which functions as a preservative. The Panel reviewed relevant animal and human data provided in this safety assessment and in a previously published safety assessment of MI and concluded that MI is safe for use in rinse-off cosmetic products at concentrations up to 100 ppm and safe in leave-on cosmetic products when they are formulated to be nonsensitizing, which may be determined based on a quantitative risk assessment.

Methylisothiazolinone may induce cell death and inflammatory response through DNA damage in human liver epithelium cells

Methylisothiazolinone (MIT) is a powerful biocide and preservative, which is widely used alone or in a 1:3 ratio with methylchloroisothiazolinone (MCIT) under the trade name of Kathons in the manufacture of numerous personal and household products. Considering that Kathons injected intravenously is distributed in the blood and then in the liver, we explored the toxic mechanism of MIT on human liver epithelium cells. At 24 h after exposure, MIT bound to the plasma membrane and the inner wall of vacuoles in the cells, and rupture of the cell membrane and nuclear envelop, autophagosome-like vacuoles formation and mitochondrial damage were observed. Cell viability dose-dependently decreased accompanying an increase of apoptotic cells, and the level of LDH, NO, IFN-gamma, IL-10 and IL-8, but not IL-1β, significantly increased in the culture media of cells exposed to MIT. Additionally, expression of autophagy-, membrane damage- and apoptosis-related proteins was notably enhanced, and the produced ATP level dose-dependently decreased with the reduced mitochondrial activity. Furthermore, the increased DNA damage and the decreased transcription activity were observed in MIT-treated cells. Meanwhile, the intracellular ROS level did not show dose-dependent change at the same time-point. Then we explored the role of autophagy in MIT-induced cytotoxicity by inhibiting or inducing the autophagic signal. Intriguingly, no additional cell death induced by autophagic modulation occurred when MIT was treated. Taken together, we suggest that MIT may induce multiple pathways of cell death and inflammatory response through DNA damage caused by rupture of the nuclear envelope.

An epidemic of allergic contact dermatitis caused by a new allergen, caprylhydroxamic acid, in moisturizers

BACKGROUND

In 2016, dermatologists in Finland suspected contact allergy in several patients using moisturizers under the trade name Apobase®. Following a formulation change, Phenostat™, which is a mixture of phenoxyethanol, caprylhydroxamic acid, and methylpropanediol, was used as a preservative in Apobase® moisturizers in Finland.

OBJECTIVES

To confirm the suspected contact allergy to Apobase® cream, oily cream, and/or lotion, and to identify the specific contact allergen and define its optimal patch test concentration.

METHODS

Thirty-nine patients with suspected contact allergy to Apobase® creams or lotion were patch tested in four Finnish dermatological clinics. The patch tests included old and new Apobase® formulas and their preservative agents: phenoxyethanol, methylpropanediol, and dilution series of Phenostat™ and caprylhydroxamic acid or its potassium salt.

RESULTS

The patch tests showed positive reactions to the new Apobase® formulas, Phenostat™, and caprylhydroxamic acid or its potassium salt, but not to the old Apobase® formulas, methylpropanediol, or phenoxyethanol.

CONCLUSIONS

We found a new contact allergen, caprylhydroxyamic acid, which caused an epidemic of allergic contact dermatitis in patients using moisturizers containing this preservative. Whether the sensitizing capacity of caprylhydroxamic acid depends on the other chemicals used in Apobase® moisturizers needs further investigation.

Detection of local inflammation induced by repeated exposure to contact allergens by use of IVIS SpectrumCT analyses

BACKGROUND

Contact allergy is characterized by local skin inflammation that, in some cases, can result in systemic immune activation.

OBJECTIVES

To investigate whether IVIS SpectrumCT analyses can be used to detect the immune response induced by contact allergens.

METHODS

Mice were repeatedly exposed to vehicle or allergens on the ears. The local and systemic responses were analysed at different times with the ProSense 750 FAST probe in IVIS SpectrumCT measurements. In addition, changes in ear thickness, cytokine profile in the skin and immunological phenotype in the draining lymph nodes and spleen were determined.

RESULTS

Local inflammation was detected by ProSense 750 FAST and correlated with changes in ear thickness, cytokine profile and immunological phenotype following exposure to the strong contact allergen 2,4-dinitrofluorobenzene. Analysis of the systemic response with ProSense 750 FAST did not show any difference between allergen-exposed and control mice, although fluorescence-activated cell sorting analysis of the spleen showed increased numbers of γδ T cells and CD11b⁺ CD11c⁺ MHCII⁺ cells in allergen-treated mice.

CONCLUSIONS

IVIS SpectrumCT analyses with ProSense 750 FAST as the probe can be used to detect local immune responses induced by contact allergens.

Methylisothiazolinone Contact Allergy Prevalence in Western Canada: Increased Detection With 2000 ppm Patch Test Allergen

Background:

Contact allergy to methylisothiazolinone (MI) or to the combination of methylchloroisothiazolinone and MI (MCI/MI) is an important and increasing cause of allergic contact dermatitis, with prevalence rates higher than 10% in some centers.

Objectives:

The objective of this retrospective chart review is to provide a western Canadian perspective on whether the positive patch testing rate to MCI/MI or MI increased during the testing period of 2008 to 2015 and whether the addition of MI at 2000 ppm resulted in increased detection.

Methods:

We conducted a retrospective chart review of patients who tested positive (n = 104) of 2177 total patients who were patch tested for MCI/MI or MI at a community dermatology clinic in Vancouver, British Columbia, Canada, from January 2008 through April 2015.

Results:

One hundred and four patients had positive patch testing results for MCI/MI, MI, or both. Positive results increased over the study period, with the highest prevalence in 2015 at 9.41% for MCI/MI, 12.94% for MI, and 15.29% for either. When testing for MI at 2000 ppm was introduced in 2013, the initial positive patch testing prevalence was 6.6%, followed by 10.1% in 2014, and 12.9% in 2015.

Conclusions:

We demonstrate an increasing prevalence of MCI/MI and MI allergy between 2008 and 2015, with the highest prevalence of 15.29% in 2015 for MCI/MI and/or MI allergy. The addition of MI 2000 ppm greatly increased the positive patch testing yield for MI. Our results support the importance of continued efforts to monitor and regulate these preservatives.

Occupational contact sensitization in female geriatric nurses: Data of the Information Network of Departments of Dermatology (IVDK) 2005-2014

BACKGROUND

Geriatric nurses (GN) have a high risk of occupational contact dermatitis (OCD), with chronic irritant contact dermatitis predominating. However, allergic contact dermatitis is an important issue as well. Little is known whether the relevant occupational allergen spectrum reported in the 1990s, including fragrances, preservatives, rubber chemicals and ingredients of surface disinfectants to be the most common sensitizers in GN, is still valid.

OBJECTIVES

To monitor the current allergen spectrum in GN with OCD and verify the validity of the patch test recommendations (baseline-, preservative-, ointment base-, rubber-, disinfectant, series and fragrances) in GN with suspected OCD given by the German Contact Dermatitis Research Group (DKG).

METHODS

Retrospective analysis of IVDK data (2005-2014) of 743 female GN with OCD, in comparison to 695 GN without OCD.

RESULTS

GN with OCD reacted significantly more frequently to both fragrance mixes, hydroxyisohexyl 3-cyclohexene carboxaldehyde (HICC), thiuram mix, zinc diethyldithiocarbamate and mercaptobenzothiazole than GN without OCD. Reactions to MDBGN, methylchloroisothiazolinone/methylisothiazolinone and oil of turpentine occurred substantially, but not significantly more frequently among GN with OCD. The latter may be due to former use of a special alcoholic liniment in geriatric care. Among material from the patients' workplaces, tetrazepam was a frequent allergen, due to dust exposure from pill crushing. Furthermore, occupationally used protective gloves, body care products as well as surface disinfectants were often tested positively.

CONCLUSIONS

The general allergen spectrum in GN with OCD is unchanged, so the DKG patch test recommendations are still valid. Prevention of occupational sensitization should focus on fragrance-free hygiene and body care products, usage of accelerator-free protective gloves and avoidance of drug dust exposure.

"Parabenoia" Debunked, or "Who's Afraid of Parabens?"

Parabens have been used as preservatives in foods, injectables, and topical preparations for nearly 10 decades. Present in nature, rapidly metabolized by skin and liver enzymes, they have an excellent safety record. However, in the past 15 years, they have been under scrutiny for their alleged estrogenic and antiandrogenic effects, as well as their putative role in promoting cancerogenesis through endocrine disruption. Scientific articles supporting these assertions have led the European Community to ban or restrict the use of some parabens. Despite that methylparaben and ethylparaben have negligible endocrine disruption activity, the food, pharmaceutical, and cosmetic industries are under pressure from scare campaigns in the media and are responding by replacing parabens with other biocides that cause multiple cases, and even worldwide epidemics, of allergic contact sensitization. In the present review, we present a balanced account of the published literature about the metabolism and potential toxicology of parabens.

The Spanish standard patch test series: 2016 update by the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC)

The Spanish standard patch test series, as recommended by the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC), has been updated for 2016. The new series replaces the 2012 version and contains the minimum set of allergens recommended for routine investigation of contact allergy in Spain from 2016 onwards. Four haptens -clioquinol, thimerosal, mercury, and primin- have been eliminated owing to a low frequency of relevant allergic reactions, while 3 new allergens -methylisothiazolinone, diazolidinyl urea, and imidazolidinyl urea- have been added. GEIDAC has also modified the recommended aqueous solution concentrations for the 2 classic, major haptens methylchloroisothiazolinone and methylisothiazolinone, which are now to be tested at 200ppm in aqueous solution, and formaldehyde, which is now to be tested in a 2% aqueous solution. Updating the Spanish standard series is one of the functions of GEIDAC, which is responsible for ensuring that the standard series is suited to the country's epidemiological profile and pattern of contact sensitization.

In situ chemical behaviour of methylisothiazolinone (MI) and methylchloroisothiazolinone (MCI) in reconstructed human epidermis: a new approach to the cross-reactivity issue

BACKGROUND

Methylisothiazolinone (MI) [with methylchloroisothiazolinone (MCI) in a ratio of 1:3, a well-recognized allergenic preservative] was released as an individual preservative in the 2000s for industrial products and in 2005 for cosmetics. The high level of exposure to MI since then has provoked an epidemic of contact allergy to MI, and an increase in MI/MCI allergy. There are questions concerning the MI/MCI cross-reaction pattern.

OBJECTIVES

To bring a new perspective on the MI/MCI cross-reactivity issue by studying their in situ chemical behaviour in 3D reconstructed human epidermis (RHE).

METHODS

MI and MCI were synthesized with (13) C substitution at positions C-4/C-5 and C-5, respectively. Their in situ chemical behaviours in an RHE model were followed by use of the high-resolution magic angle spinning nuclear magnetic resonance technique.

RESULTS

MI was found to react exclusively with cysteine thiol residues, whereas MCI reacted with histidines and lysines. The reaction mechanisms were found to be different for MI and MCI, and the adducts formed had different molecular structures.

CONCLUSION

In RHE, different MI/MCI reactions towards different nucleophilic amino acids were observed, making it difficult to explain cross-reactivity between MI and MCI.

Formaldehyde may be found in cosmetic products even when unlabelled

Concomitant contact allergy to formaldehyde and formaldehyde-releasers remains common among patients with allergic contact dermatitis. Concentration of free formaldehyde in cosmetic products within allowed limits have been shown to induce dermatitis from short-term use on normal skin. The aim of this study was to investigate the formaldehyde content of cosmetic products made in Lithuania. 42 samples were analysed with the chromotropic acid (CA) method for semi-quantitative formaldehyde determination. These included 24 leave-on (e.g., creams, lotions) and 18 rinse-off (e.g., shampoos, soaps) products. Formaldehyde releasers were declared on the labels of 10 products. No formaldehyde releaser was declared on the label of the only face cream investigated, but levels of free formaldehyde with the CA method was >40 mg/ml and when analysed with a high-performance liquid chromatographic method - 532 ppm. According to the EU Cosmetic directive, if the concentration of formaldehyde is above 0.05% a cosmetic product must be labelled "contains formaldehyde". It could be difficult for patients allergic to formaldehyde to avoid contact with products containing it as its presence cannot be determined from the ingredient labelling with certainty. The CA method is a simple and reliable method for detecting formaldehyde presence in cosmetic products.

Isothiazolinones: sensitizers not to miss in children

Isothiazolinone is known to be a sensitizer and a frequent cause of contact dermatitis in adults. Cases of contact dermatitis have also recently been reported in children. Derivatives of isothiazolinone, such as methylisothiazolinone (MI) and methylchloroisothiazolinone (MCI), are commonly used in the care products of babies and children. This allergen should not be missed.

Methylisothiazolinone: dermal and respiratory immune responses in mice

Methylisothiazolinone (MI), a widely used chemical preservative in industrial and household products, and cosmetics, has been associated with allergic contact dermatitis. However, the asthmogenic capacity of MI is currently unknown. In this study, we investigated the capacity of MI to elicit asthma-like responses in a validated mouse model. On days 1 and 8, mice (C57Bl/6 and BALB/c) were dermally treated with MI or vehicle on each ear. On day 15, mice received a single intranasal challenge with MI or vehicle. Immediately after the challenge, the early ventilatory response was measured using a double chamber plethysmograph. One day later, airway hyperreactivity, pulmonary inflammation and immune-related parameters were assessed. Dermal treatment with MI in both C57Bl/6 and BALB/c mice induced increased T- and B-cell proliferation in the auricular lymph nodes, along with IFN-γ production and limited increases in total serum IgE, confirming dermal sensitization. An airway challenge with MI led to an early ventilatory response (decreased breathing frequency), indicative for acute sensory irritation. However, 24h later no allergic respiratory response (no airway hyperreactivity (AHR) nor pulmonary inflammation) was found in either mouse strains. Our study indicates that MI can be classified as a strong dermal sensitizer and irritant, but not an asthmogen after initial dermal sensitization, followed by an airway challenge.