Exogenous and endogenous factors in skin irritation

Howard I. Maibach: Extraordinary Leadership in Integrating Key Concepts Underpinning Our Understanding of Percutaneous Absorption and Occupational Dermatology

The purpose of the present article is to briefly highlight some contributions of Prof. Howard I. Maibach to the field of dermatology. After a few introducing remarks regarding Howard's personal career, the article specifically reviews contributions to the understanding of percutaneous absorption and to occupational dermatology. He and his companions/coworkers established and introduced experimental prerequisites to better study and understand percutaneous absorption - both in vitro and in vivo. Not less influential was his contribution to occupational dermatology acting as a founding member of the International Contact Dermatitis Research Group and coinaugurating the North American Contact Dermatitis Group. These groups have been very active ever since. As an academic teacher, he inspired young colleagues to perform original research work and to establish their own working groups. He has done this most successfully with many fellows who worked with him over the years, and who are now leading departments or companies dedicated to dermatological research all over the world. Probably this is his most important and lasting achievement.

Influence of tumour necrosis factor-α polymorphism-308 and atopy on irritant contact dermatitis in healthcare workers

BACKGROUND

Chronic irritant hand dermatitis is an issue for healthcare workers and may negatively impact infection control.

OBJECTIVES

We examined the effects of a G to A transition at position -308 on the tumour necrosis factor-α (TNF-α) gene on chronically damaged skin of healthcare workers during exposure and recovery from repetitive hand hygiene, after intensive treatment, and on the irritant response in normal skin.

PATIENTS/MATERIALS/METHODS

In 68 healthcare workers with irritant hand dermatitis, we genotyped TNF-α-308 and measured the epidermal response via quantitative digital imaging, erythema, dryness, and barrier integrity.

RESULTS

Excess hand erythema decreased with hand hygiene exposure and increased during time off for AA/GA genotypes, but had opposite effects for GG. AA/GA had smaller reductions in dryness with lotion treatment and larger reductions in excess erythema than GG. The atopic diathesis and heightened neurosensory irritation resulting from water and lactic acid significantly influenced the responses. Repeated exposure to water and sodium lauryl sulfate (0.05, 0.1%) produced higher erythema in normal skin for AA/GA than for GG.

CONCLUSIONS

This study provides evidence that the TNF-α polymorphism at -308 and an atopic history impact the severity of irritation and recovery from exposure and response to treatment for common hand skin products in both chronic irritant hand dermatitis and normal skin.

Simultaneous sodium lauryl sulphate testing improves the diagnostic validity of allergic patch tests. Results from a prospective multicentre study of the German Contact Dermatitis Research Group (Deutsche Kontaktallergie-Gruppe, DKG)

BACKGROUND

There is evidence that a higher skin susceptibility may induce nonspecific erythematous or weak positive reactions to contact allergens in patch testing.

OBJECTIVES

To evaluate whether simultaneous application of sodium lauryl sulphate (SLS) along with diagnostic patch tests with contact allergens can provide information regarding skin irritability which may help to discriminate allergic from nonspecific irritant reactions to contact allergens.

METHODS

Between July 2001 and June 2003, this prospective study collected patch test data of 5971 patients from 19 centres in Germany and Austria in the Information Network of Departments of Dermatology (IVDK). In addition to contact allergens (standard series and eight known 'problematic' allergens with a low reaction index and a high positivity ratio: 1,3-diphenylguanidine, amerchol L-101, benzalkonium chloride, benzoyl peroxide, cocamidopropyl betaine, octyl gallate, phenyl mercuric acetate and propylene glycol), patches with SLS 0.5% and 0.25% aq. were applied. Reactions to the allergens and to SLS were analysed at the IVDK data centre. The association between an erythematous or positive reaction to a certain allergen and an irritant reaction to SLS was assessed with logistic regression analysis, at the same time controlling for the influence of age and sex.

RESULTS

Of the 29 allergens of the standard series, 23 and 21 gave a higher percentage of nonspecific erythematous reactions in patients with an irritant reaction to 0.25% and 0.5% SLS, respectively, in comparison with SLS-negative patients. All eight 'problematic' allergens gave an increased percentage of nonspecific erythematous reactions. Similarly, 22 and 21 allergens of the standard series gave a higher percentage of positive allergic reactions in patients with an irritant reaction to 0.25% and 0.5% SLS, respectively, and seven of the eight 'problematic' allergens gave a higher percentage of positive allergic reactions (exception: octyl gallate). For most allergens, the markers of skin reaction (reaction index and positivity ratio) were worse in SLS-positive patients. Differences were more pronounced when testing with SLS 0.25% than with SLS 0.5%.

CONCLUSIONS

Because there is a convincing association between skin irritability (evaluated by SLS test) and the degree of skin reaction to contact allergens, the SLS test may help in deciding whether a doubtful erythematous or weakly 'positive' skin reaction should be interpreted as allergic or irritant.

Artificial disruption of skin barrier prior to irritant patch testing does not improve test design

BACKGROUND

Irritant patch testing is often performed as a 24- or 48-h occlusive patch test with low concentrations of sodium lauryl sulphate (SLS).

OBJECTIVES

The aim of this study was to investigate potential ways to shorten this test procedure and obtain precise test results.

PATIENTS AND METHODS

Thirty-six healthy volunteers underwent irritant patch testing with different pretreatments (PT) of the test fields. Occlusive test chambers were applied on the upper back with SLS 0.5%, 1%, 2% and 5% in large Finn Chambers(R). The patches were removed after 4 and 24 h, respectively, depending on the concentration used. Test fields were pretreated as follows: PT 0, field without any PT (control); PT 1, prick with lancet; PT 2, prick with test stamp; PT 3, scratch with lancet; PT 4, incision with standardized incision instrument (0.1-0.2 mm depth). Skin reactions were evaluated by transepidermal water loss (TEWL), skin erythema and skin hydration and as well by a visual score (VS) at 4, 24 and 72 h.

RESULTS

Our data show an obvious distinction between PT 0-2 and PT 3-4 at all measurement methods. The average TEWL values with PT 3-4 were higher than those with PT 0-2, especially on the 4-h course. This distinction may derive from the shape and size of the skin impairment achieved by PT 3-4, leading to a mechanical barrier disruption. However, SLS may infiltrate directly into deeper skin layers supported by capillarity. Consequently, no or little penetration through the epidermis and interaction with its structures occurs, which is responsible for irritant skin reactions. The SLS dose in the upper skin layers is therefore lower at these PTs. The lower remaining dose of SLS also explains this distinction, especially for the VS. Additionally, there are presumed reactions in deeper layers of the epidermis and dermis at PT 3-4.

CONCLUSIONS

In summary, all data suggest a different reaction pattern from the classical irritant response. Therefore, application without any PT seems to be best suited for irritancy skin testing, especially for visual assessment. PTs prior to irritant patch testing have been shown to be unjustifiable.

Ethnicity as a possible endogenous factor in irritant contact dermatitis: comparing the irritant response among Caucasians, blacks, and Asians

Irritant contact dermatitis (ICD) is a common dermatological diagnosis in which endogenous and exogenous factors have been implicated. This review explores ethnicity as a possible endogenous factor. While there is a clinical consensus that blacks are less reactive and Asians are more reactive than Caucasians, the data supporting this hypothesis rarely reaches statistical significance. The studies reviewed do not provide sufficient evidence to determine that race is a predisposing factor to the degree of irritation in ICD. We conclude that race could be a factor in ICD, which has practical consequences regarding topical product testing requirements, an ever-expanding global market, occupational risk assessment, and the clinical thinking about ICD. Pitfalls in defining differences are discussed.

Effects of premilking and postmilking teat disinfectants on teat skin condition

An incomplete block split-plot design with repeated measures was used to test the effects of eight combinations of premilking and postmilking teat disinfectants on teat skin and teat end condition over a 6-wk period. These combinations included iodine, sodium chlorite, lactic acid, and orthophosphoric acid. Visual assessments of teat skin and teat ends were made on the teats of 101 cows. Teat skin thickness, teat end thickness, and transepidermal water loss were assessed for the teats of 50 cows. The interaction of predip and postdip had no effect on teat condition. Postdip had a significant effect on transepidermal water loss, visual teat skin condition, and visual teat end condition. The 1% iodine postdip was associated with the poorest teat skin condition.

Irritant contact dermatitis. Clues to causes, clinical characteristics, and control

Skin irritation can cause poorly defined nonimmunologic cutaneous changes that may cause diagnostic confusion. Clinical signs include vesicles, papules, bullae, erythema, edema, scaling, and lichenification. In some patients, this condition, termed irritant contact dermatitis, is indistinguishable from endogenous, dyshidrotic, nummular, and atopic dermatitis. Irritant contact dermatitis has only a few typical characteristics. The diagnosis is generally based on clinical appearance, history and, when indicated, diagnostic patch testing to rule out an allergic component. Elimination of the offending agent and protection from further exposure are important in both diagnosis and management. The dermatitis usually heals once the irritant is eliminated, and reexposure should be minimized for weeks to months, if not permanently.

Altered permeability and disordered cutaneous immunoregulatory function in mice with acute barrier disruption

In vivo and in vitro T-cell-activating ability of murine epidermal cells (EC) was investigated in acutely barrier-disrupted skin by extraction of epidermal lipids with acetone or removal of corneocytes by tape stripping. Contact sensitivity (CS) to 2,4-dinitrofluorobenzene (DNFB) and picryl chloride (PCl) and contact photosensitivity (CPS) to tetrachlorosalicylanilide (TCSA) were significantly augmented when challenged or sensitized at sites treated with acetone 24 h before, compared with the intact skin. CS to DNFB was also enhanced by tape stripping, but not by water rubbing, suggesting that physical stress or a toxic effect of acetone was not responsible for the augmentation. Semi-quantification of TCSA-EC photoadducts showed markedly increased permeability of hapten in the epidermis 24 h after acetone treatment. Bioactive IL-1alpha was more pronounced in barrier-disrupted than in intact skin. Lymph node T cells from PCl-sensitized mice proliferated significantly more in a hapten-specific and co-stimulatory molecule-dependent manner in response to trinitrophenylated (TNP) EC from acetone-treated skin than to those from untreated skin. Immunofluorescence staining of epidermal sheets and flow cytometric analysis of dispersed EC showed that subpopulations of Langerhans cells (LC) in acetone-rubbed or tape-stripped skin expressed major histocompatibility complex class II CD54 and CD86 molecules at levels higher than the rest of LC and LC from water-treated or untreated epidermis. Therefore, not only increased permeability of hapten through the epidermis but also altered immune functions of EC potentiate T-cell activation in acute barrier disruption. Such augmentation of immune reactivity may be critical to elimination of environmental noxious agents that penetrate easily into the barrier-disrupted epidermis.

Increased human gingival blood flow induced by sodium lauryl sulfate

Laser Doppler flowmetry was used in 14 subjects to investigate the effect of sodium lauryl sulfate (SLS) on gingival microcirculation. SLS, the most widely used detergent in toothpastes, exhibits a denaturing property, increases oral mucosal permeability and may cause epithelial desquamation of oral soft tissues. Gingival blood flow (GBF) was measured bilaterally 3 mm above the gingival margin, between the central and lateral maxillary incisors, before and after application of 1.5% SLS for 90 s to the gingiva on one side. The contralateral side served as a control with water application only. Relative changes in GBF were measured for 15 min on both sides. SLS increased the median GBF significantly between the 2nd and 10th min with a peak at 8 min, whereafter the flow decreased towards baseline. On the contralateral side, GBF initially declined before returning to baseline. 10 subjects felt a burning pain from the gingiva after SLS application and GBF increased in all of them. SLS increased the relative gingival blood flow presumably due to its penetrating and irritative properties, which resulted in vasodilatation. Laser Doppler flowmetry may be a useful non-invasive method for intraoral testing of different agents meant for oral use.

Immediate irritant reactions to benzoic acid are enhanced in washed skin areas

Factors affecting immediate irritant skin reactions are poorly understood. Our purpose was to study the effect of washing on reactions to benzoic acid, a well-known immediate-type irritant. 12 test subjects washed their left upper arms with a diluted dishwashing liquid 2X daily for 6 days. Benzoic acid in a dilution series was tested on both upper arms on days 0, 3 and 6. The reactions were graded visually, and the blood flow, skin color, transepidermal water loss and electrical capacitance of the test sites were measured. On days 3 and 6, the benzoic acid reactions were stronger on the washed arm than on the control arm. This was clinically visible and was associated with changes in blood flow and skin color measurements. Washing itself did not usually cause visible erythema, but transepidermal water loss increased and electrical capacitance decreased. Low concentrations of irritant substances, such as benzoic acid, may cause clinically relevant reactions in repeatedly washed skin. This should be taken into consideration in assessing product safety in the cosmetic, medical and household chemical industries, and when tests for chemical skin irritancy are designed and the results of such tests interpreted.

Survey of dairy managers in the Pacific Northwest identifying factors associated with teat chapping

Telephone interviews were conducted to evaluate the association of teat chapping with combinations of premilking and postmilking teat disinfectants (predip and postdip), other management practices, and climatic conditions. Holstein dairies (n = 100) in the DHIA SCC program were randomly selected from three northwest regions. During nonwinter seasons, herd managers using an iodophor dip without skin conditioner both premilking and postmilking were 9.7 times more likely to report chapping than were those using iodophor with conditioner. The herd managers least likely to report chapping problems were those using conditioner in both the predip and postdip. Use of conditioner in postdip only was associated with intermediate frequency of reported chapping. No conditioner in either predip or postdip was associated with the greatest frequency of reported chapping. Herd managers using a different germicide in the predip and postdip reported more chapping than herd managers using the same germicide. The frequency of chapping was highest during winter in all regions, and the percentage of herd managers reporting chapping within a region was associated with the temperature extremes of the region. For seasons other than winter, characteristics of predip and postdip combinations and parlor exit or barn design were the management factors that best described an association with reported chapping.

The modulation of skin irritation

Irritant contact dermatitis (ICD) is a multifactorial disease, the onset and modulation of which depend on both endogenous and exogenous factors. Among the former, age, race, site, sex and history of dermatitis may all be important. Such variables can now readily be quantified by objective noninvasive techniques, such as measurement of transepidermal water loss (TEWL). Moreover, effects of irritants on the epidermis are related to the particular chemical properties of each molecule, contributing further to clinical heterogeneity. Release of cytokines and mediators may be initiated by a number of cells, including living keratinocytes and those of the stratum corneum, thus modulating inflammation and repair. Furthermore, differences in mechanisms of inflammation between acute and chronic ICD may exist, the former being characterized predominantly by inflammation, the latter by hyperproliferation and transient hyperkeratosis. These findings may explain the complexity and difficulty of investigating ICD. Better understanding and quantification of these mechanisms may lead to identification of high-risk individuals and more effective prevention and treatment.

Effect of age and sex on the elicitation of irritant contact dermatitis

Irritant contact dermatitis causes significant disability to numerous consumers and individuals in industry. Knowledge of the prevalence of this disease remains inadequate. Irritant contact dermatitis occurs in workers engaged in occupations where the subjects are exposed to different types and doses of irritants. The intensity of the reaction depends on the quality and the quantity of exposure. Irritant thresholds and dose responses depend on many different factors. This article reviews the clinical and physiological parameters that affect the age and sex related differences in irritant contact dermatitis.

Changes in transepidermal water loss and cutaneous blood flow during the menstrual cycle

This study quantified irritant susceptibility and blood vessel reactivity in normal women over the course of the menstrual cycle. Such alterations were studied by observing vasodilation from topical application of methyl nicotinate (MN) on the following days of the menstrual cycle: (i) the day of putative maximal estrogen secretion; (ii) the day of maximal progesterone secretion; (iii) the day of minimal estrogen/progesterone secretion. These responses were evidenced by changes in the following dose response characteristics: the initial response (IR), the peak response (PR) and the area under the curve (AUC). Baseline laser Doppler velocimetry (LDV) blood flow values and transepidermal water loss (TEWL) values on normal skin were also obtained. No significant differences existed for any of the dose-response characteristics (IR, PR, AUC) when the values for the 3 testing days were compared to one another. Significant differences did exist for baseline TEWL values when comparing the day of maximal estrogen secretion to the day of minimal estrogen/progesterone secretion. TEWL was higher on the day of minimal estrogen/progesterone secretion as compared to the day of maximal estrogen secretion on both back (p = 0.037) and forearm (p = 0.021) sites, suggesting that the skin barrier function is less complete on the days just prior to the onset of the menses as compared to the days just prior to ovulation. Significant differences in baseline blood flow also existed for the day of maximal estrogen secretion as compared to the day of maximal progesterone secretion, with higher baseline blood flow recorded on the day of maximal progesterone secretion on both the back (p = 0.021) and forearm (p = 0.009) sites.

Cutaneous sodium lauryl sulphate irritation potential: age and regional variability

To investigate differences in response to irritation according to age and site seven young-adult and eight elderly females were exposed to 0.25% sodium lauryl sulphate (SLS) under patch-test occlusion for 24 h. Ten anatomical regions were tested: forehead, upper arm, volar and dorsal forearm, postauricular, palm, abdomen, upper back, thigh, and ankle. The skin responses were evaluated 24 h post-patch removal by visual scoring and by transepidermal water loss measurements (TEWL). Non-treated symmetrical anatomical regions served as controls. SLS induced a mild erythematous reaction on most anatomical regions except the palm and TEWL was significantly increased as compared with controls. The elderly group demonstrated significantly less susceptibility to SLS-induced irritation for most regions of the body as indicated by visual scores and TEWL measurements. In addition, evaluation of the stratum corneum water content following SLS irritation demonstrated lower responses in the old age group for most regions. The thigh had the highest reactivity and the palm the lowest, in both age groups. These data suggest that young adult skin is more sensitive to SLS than old skin and that SLS irritation varies considerably with respect to region. Moreover, objective TEWL measurements seem to be a better indicator of irritant susceptibility, especially in the elderly, than clinical evaluation by visual scoring.

The irritancy of metalworking fluids: a laser Doppler flowmetry study

Irritant contact dermatitis is common in metalworkers exposed to metalworking fluids (MWF). The irritancy of 3 commercially available water-based cutting fluids in maximal user's concentration and 2 neat oils was investigated in 23 healthy volunteers. Additionally, the irritancy of some groups of components of the cutting fluids was studied. After Sellotape stripping, repeated patch tests were performed over 5 days and evaluated by a visual score (VS) and by laser Doppler flowmetry (LDF). In general, the MWF caused marginal skin irritation. In a comparison of the MWF and water, the cutting fluids were ranked higher in irritancy than the neat oils, but the effect of only one cutting fluid could be distinguished from that of water. The components of the cutting fluids also caused no strong reactions. The LDF response showed that one emulsifier was more irritant than water and according to the VS, one corrosion inhibitor was the most irritant. The correlation coefficient between the VS and the LDF response was probably diminished by a strong adverse reaction to the fixing tape in many volunteers. From this experiment, it was concluded that MWF are generally only mildly irritant when used in proper concentrations. However, orthoergic contact dermatitis often develops as a result of repeated and cumulative subclinical insults, in which MWF, especially water-based, play a crucial role because exposure at work is often extensive.

Epicutaneous patch testing: current trends and controversial topics

In the 20th century, epicutaneous patch testing has played an integral and central role in the assessment of allergic contact dermatitis and therefore in general dermatologic practice. After recent verification of the safety and accuracy of patch testing by the Food and Drug Administration, domestic distribution of testing materials has resumed for the first time in 5 years. Because of the importance of this procedure, it is timely to review current standards of epicutaneous patch testing with emphasis on proper use and interpretation, clinical applications, trends in allergic contact dermatitis, and selected controversial issues.