A case of contact dermatitis due to impurities of cetyl alcohol

Seven cases of contact dermatitis due to stearyl alcohol contained in topical medications

Stearyl alcohol is found in various cosmetics and topical medications and is regarded as safe. Allergic contact dermatitis is reported due to this chemical on rare occasions. We report seven cases, comprising three men and four women aged between 36 and 62 between the years 2013 to 2019, of allergic contact dermatitis due to the use of topical medication, where the patient showed a positive result to a patch test using stearyl alcohol. There were 10 topical medications that we considered to be the cause of this: three were from Oronine^® H ointment, two from Eurax^® cream, one from Eurax H cream, and four from topical antifungal medications. All these medications contained stearyl alcohol. Seven cases of patch tests with stearyl alcohol all showed positive results. Moreover, having done a patch test with cetyl alcohol, two out of three tests showed positive. When researching allergic contact dermatitis due to topical medications, it is important to test for allergy to stearyl alcohol as well as their main ingredients, because it is contained in numerous products and has the ability to cause allergic contact dermatitis.

Safety of Cetylated Fatty Acids as a Novel Food pursuant to Regulation (EU) 2015/2283

Following a request from the European Commission, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was asked to deliver an opinion on an application for cetylated fatty acids as a novel food (NF) pursuant to Regulation (EU) 2015/2283. The NF concerns primarily a mixture of cetylated myristic acid and cetylated oleic acid synthesised from cetyl alcohol, myristic acid and oleic acid, and to a lesser degree, other cetylated fatty acids and other compounds from olive oil. The NF is intended for use in food supplements for the general adult population. The highest dose tested in a subchronic toxicity study in rats, i.e. 4,500 mg/kg per day, was considered to be the no-observed-adverse effect level. By applying the default uncertainty factor of 200 as suggested by the EFSA Scientific Committee (2012), and considering a default body weight of 70 kg for the adult target population, this would result in an intake of 1.6 g per day, which is lower than the maximum intake proposed by the applicant (i.e. 2.1 g per day). The Panel concludes that the NF, cetylated fatty acids, is safe at an intake of 1.6 g per day for the intended target population, i.e. adults.

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.

Men's Facial Moisturizers in the Metrosexual Era

BACKGROUND

Manufacturers are increasingly branding personal care products (PCPs) specifically for men.

OBJECTIVE

The aim of the study was to characterize ingredients and claims of facial moisturizers marketed to men.

METHODS

Men's facial moisturizers from 7 different online retailers were identified in June-September 2018. Ingredients were grouped and identified per the Ingredient Database of the Personal Care Products Council. Potential allergens were identified using the 2017 American Contact Dermatitis Society (ACDS) Core Allergen Series and 2017-2018 North American Contact Dermatitis Group Screening Series.

RESULTS

Sixty-five men's facial moisturizers were identified with a total of 1930 ingredients. On average, there were 12 ACDS Core and 9 North American Contact Dermatitis Group Screening allergens per product. A total of 70.8% of products contained between 6 and 15 ACDS Core allergens. The most notable allergens were fragrances (present in 98.5% of products), propylene glycol/derivatives (32.3%), parabens (29.2%), and alkyl glucosides (26.2%). Interestingly, less than 10% of products contained the most common allergenic preservatives in PCPs: formaldehyde releasers and methylisothiazolinone.

CONCLUSIONS

Men's facial moisturizers commonly contain fragrances, emulsifiers, and glucosides but relatively few allergenic preservatives. This may reflect changes in modern PCP preservation. These findings are important for modern dermatologists to be aware, especially in a new era of male skincare.

Allergic Contact Dermatitis Secondary to Moisturizers

Background: Moisturizers are cosmetic products used routinely to manage various skin conditions. Even though moisturizers are often thought to have minimal or no adverse reactions, allergic contact dermatitis (ACD) to these products can develop in some cases. Methods: We studied ingredients included in 3 of the most commonly used moisturizer brands, identified their presence in standard patch testing series, and evaluated their allergenic potential, categorizing the allergens as frequent or infrequent. The standard patch testing series used as reference were the Thin-layer Rapid Use Epicutaneous patch test (T.R.U.E. test), the North American Contact Dermatitis Group (NACDG) screening standard series, and the American Contact Dermatitis Society (ACDS) core allergen series. Results: Aveeno, Cetaphil, and Cerave products had a total of 12, 14, and 9 potential allergens, respectively, the majority of which were infrequent and not included in standard patch testing series. Conclusion: Being aware of the allergenic potential of commonly used moisturizers may help healthcare providers when evaluating patients with ACD. Further testing is recommended in a targeted manner when suspecting ACD with negative standard patch testing series or when ACD is refractory to treatment.

Risk evaluation of impurities in topical excipients: The acetol case

Pharmaceutical excipients for topical use may contain impurities, which are often neglected from a toxicity qualification viewpoint. The possible impurities in the most frequently used topical excipients were evaluated in-silico for their toxicity hazard. Acetol, an impurity likely present in different topical pharmaceutical excipients such as propylene glycol and glycerol, was withheld for the evaluation of its health risk after dermal exposure.

An ex-vivo in-vitro permeation study using human skin in a Franz Diffusion Cell set-up and GC as quantification methodology showed a significant skin penetration with an overall K_p value of 1.82×10⁻³ cm/h. Using these data, limit specifications after application of a dermal pharmaceutical product were estimated. Based on the TTC approach of Cramer class I substances, i.e. 1800 µg/(day∙person), the toxicity-qualified specification limits of acetol in topical excipients were calculated to be 90 µg/mL and 180 µg/mL for propylene glycol and glycerol, respectively.

It is concluded that setting specification limits for impurities within a quality-by-design approach requires a case-by-case evaluation as demonstrated here with acetol.

Allergic contact dermatitis to an expired moisturiser

A 64-year-old man developed an allergic contact dermatitis while using an expired sorbolene cream. Patch tests to the product ingredients were all negative. Repeated open application test to the expired product produced a strong reaction while an identical-brand non-expired product did not elicit a reaction, suggesting the presence of an unidentified degradation product or compound, acting as an allergen in the expired product. This case is intriguing in that it contrasts the ubiquitous use of over-the-counter topical agents with the exceedingly low incidence of contact dermatitis to expired topical products.

Skin disorders in amputees

BACKGROUND

Dermatologic problems restrict the normal use of a prosthetic limb. The importance of contact dermatitis to skin morbidity in a population of amputees and the selection criteria for patch testing have not been clearly defined.

OBJECTIVE

We describe the range of dermatoses seen in a population of amputees and examine the incidence, causes, and patterns of contact dermatitis.

METHODS

This is a questionnaire-based, cross-sectional study of 210 amputees. Those with a skin problem were assessed by a dermatologist. Patch testing was undertaken in patients with persistent dermatitis.

RESULTS

A total of 34% of amputees experienced a skin problem. Lesions resulting from friction, pressure, and occlusion are common. Allergic contact dermatitis is seen in a third of patients with stump dermatitis. There are no features that distinguish allergic from irritant (chemical or physical) dermatitis.

CONCLUSION

Dermatologic problems are common in prosthetic limb users. Allergic contact dermatitis is a significant problem, and all patients with dermatitis on the residual limb should be patch tested.

National rates and regional differences in sensitization to allergens of the standard series. Population-adjusted frequencies of sensitization (PAFS) in 40,000 patients from a multicenter study (IVDK)

Sensitization rates to contact allergens vary between centers and are influenced by sex and age. Eliminating the latter 2 factors by standardization of data by age and sex, the present analysis addresses possible differences between centers remaining after elimination of these confounders, and analyzes other factors which might influence rates, e.g., the MOAHL index. Overall standardized rates were well within the range reported in previous studies and may be regarded as representing the rates of the "patch test population" in Central Europe (e.g., nickel sulfate 12.9%, fragrance mix 10.5%, balsam of Peru 7.3%, thimerosal 5.6%). For this analysis, data of those departments which contributed more than 2000 patients, or of those with extreme proportions concerning sex, age and occupational cases were selected. Patients from these 10 departments differed considerably with regard to the items of the MOAHL index and with regard to standardized rates. The items of the MOAHL index proved to be suitable for describing different patch test populations and for explaining some differences between centers. Only 'atopic dermatitis' seems to have little influence on (standardized) rates. Face dermatitis is not yet represented in the MOAHL index, but should be included, together with age > 40 years, in an extended index (acronym: MOAHLFA). Regional allergen exposure (with striking differences between East Germany, West Germany and, to a lesser extent, Austria) seems to have a great influence on the sensitization pattern observed in a department. In addition, sociological factors may influence sensitization rates, which is exemplified by high rates of nickel allergy in a socially defined subgroup. Future studies should focus on these factors, as well as on factors concerning patch test practices and quality control.