Recommendation to include fragrance mix 2 and hydroxyisohexyl 3-cyclohexene carboxaldehyde (Lyral®) in the European baseline patch test series

Should Hydroxyisohexyl 3-Cyclohexene Carboxaldehyde (Lyral®) still be part of the Baseline Series?

BACKGROUND AND OBJECTIVES

Hydroxyisohexyl 3-cyclohexene carboxaldehyde (HICC), or Lyral®, is a fragrance marker that is part of the Fragrance Mix II (FM II) and is still patched as an independent allergen within the European and other baseline series despite the European Commission banning its use in cosmetics in 2021. We aimed to study the prevalence of sensitization to the HICC in Spain and its simultaneous positivity with the FM II to determine whether it should be part of the Spanish baseline series.

MATERIAL AND METHOD

We analysed all consecutive patients simultaneously patch-tested with HICC and FM II within the Spanish Contact Dermatitis Registry (REIDAC) from June 1st, 2018 through December 31st, 2023.

RESULTS

A total of 96 (0.8%) out of 12,029 patients analysed yielded positive to HICC and 396 (3.3%) to FM II. In 53% and 64% of the patients, respectively, findings were considered currently relevant. A total of 72 out of 96 (75%) HICC positives would be detected if only FM II was patched.

CONCLUSIONS

Prevalence of HICC sensitization in Spain is low and has decreased in recent years. HICC is a prohibited fragrance in cosmetics and FM II detects 3 in 4 sensitized patients. Our results suggest that HICC should remain outside the Spanish baseline series and support its exclusion from the European baseline series.

Surprising results of patch testing with the baseline series in patients with photocontact allergy to ketoprofen

OBJECTIVE

Photoallergic reactions due to topical ketoprofen are common. As some simultaneous contact allergies have been described in the literature, we aimed to get an overview of the pattern of reactivity towards common allergens in the baseline series in ketoprofen-photoallergic individuals.

METHODS

Using our database, we found 94 patients with photocontact allergy to ketoprofen diagnosed during 1999-2018. Approximately 12 800 patients patch tested with the baseline series during the same time frame served as controls. Data on patch testing with the baseline series of 518 individuals belonging to the general population were obtained from an earlier study, and a comparison of allergy rates was made with the ketoprofen group.

RESULTS

Contact allergy to fragrance mix I and Myroxylon pereirae was overrepresented among patients with photocontact allergy to ketoprofen (42.3% vs. 6.6% and 47.9% vs. 6.6%, p < 0.001, respectively). Significant overrepresentation was also shown for 4-tert-butylphenolformaldehyde resin (PTBP-F-R), phenol formaldehyde resin (PFR-2), black rubber mix, budesonide (all p < 0.001), and fragrance mix II (p = 0.02). The pattern was similar, but with lower significance levels for fragrance mix II and budesonide, regardless of whether or not the individuals had been photopatch tested because of a suspected photoallergic contact dermatitis from ketoprofen.

CONCLUSION

Contact allergy to fragrance mix I, Myroxylon pereirae, black rubber mix, PFR-2, PTBP-FR, and to a somewhat lower extent, to fragrance mix II and budesonide, is common in individuals photoallergic to ketoprofen. It remains to be seen whether sensitisation to ketoprofen leads to simultaneous sensitisation to a number of other, chemically non-related, substances.

Quantitative risk assessments of skin sensitization for 26 allergens in different consumer products in the Saudi market

Fragrance chemicals are ubiquitous in cosmetics; however, they have been linked to allergic contact dermatitis. Allergy prevention involves two main strategies. Firstly, consumers are protected by limiting the maximum concentration of fragrance in a given product to avoid inducing allergies. Secondly, consumers who are already sensitized are protected by having the presence of such fragrance communicated to them. In this study, a validated GC-MS method was employed to quantify 26 allergens in 108 products marketed in Saudi Arabia.Additionally, a quantitative risk assessment (QRA) was performed on the studied cosmetics to determine the risk of inducing allergies. The results indicated that most allergens were present at acceptable concentrations, while 19 products carried a risk of inducing allergies. Furthermore, Lilial and Lyral, two prohibited fragrances, were detected in 97 products. It should be emphasized that this is the first study conducted in Saudi Arabia to evaluate the safety of the well-known 26 fragrance allergens. Hence, this study can potentially serve as a regional standard for future research.

Fragrance Contact Allergy - A Review Focusing on Patch Testing

Fragrance materials are widely used in various types of products in daily life and many of them can be contact sensitizers. Contact allergy to fragrances has been reported to be common worldwide. Unlike other groups of contact allergens such as metals and preservatives, fragrance materials in consumer products can be present as single fragrance chemicals or in the form of mixtures known as natural complex substances. Due to the complexity of the fragrance materials and the high number of fragrance substances known to cause contact sensitization, selecting suitable materials for patch testing is challenging. Emerging fragrance markers have been additionally introduced in different baseline series for screening to enhance the rate of fragrance contact allergy detection. Moreover, there have been continual updates on basic knowledge, clinical perspectives, sources of exposure, and regulations on the use of fragrance materials. Avoiding pitfalls while performing patch testing with fragrance test materials is also crucial and should not be overlooked. Therefore, this review aims to update knowledge to provide a high-quality holistic approach to fragrance contact allergy diagnosis and management.

Trends in contact sensitization, results, and implications from a contact dermatitis clinic in Israel

BACKGROUND

The baseline series includes common allergens, evolves over time, and differs by location. Our study aims to characterize allergen sensitization trends among the Israeli population during the last two decades, compare our results to American and European registries, as well as to highlight significant allergens in additional series outside the European baseline series (OEBS).

METHODS

We analysed patch test results of 2086 patients from a designated contact dermatitis clinic in Tel Aviv between 2019 and 2022, compared them to European and North American registries and to 2156 patch test results conducted in Israel two decades ago.

RESULTS

38.6% of patients had at least one positive reaction to an allergen in the European baseline series (EBS), nickel sulphate (14.6%), fragrance mix I (4.6%), and Methylchloroisothiazolinone methylisothiazolinone (MCI/MI; 3.7%) were the most common among them. N-Isopropyl N-Phenyl-4-Phenylenediamine (NIPPD; 0%), Propolis (0.1%), Sesquiterpene lactone mix (0.1%), and Budesonide (0.1%) elicited a sensitization frequency significantly lower than the proposed threshold for baseline inclusion. Chi-square test revealed a statistically significant decrease (p < 0.05) in the sensitization frequency of fragrance mix I, Formaldehyde, Potassium dichromate, Neomycin sulphate, Myroxylon pereirae, Sesquiterpene lactone, and NIPPD during the last two decades. The overall sensitization frequency to the majority of allergens was lower in our cohort in comparison to the North American and European registries.

CONCLUSIONS

MCI/MI and 2-hydroxyethyl methacrylate-2 (HEMA) are common, relevant allergens, with high SPIN (significance and prevalence index number) and should be better regulated by the authorities. While among the EBS, NIPPD, Propolis, Sesquiterpene lactone, and Budesonide usually do not elicit a positive reaction and therefore should be reconsidered in baseline series, among the OEBS, Chloramphenicol, Quaternium 15, Propyl gallate, and Amerchol L101 have elicited high SPIN values and should be vigilantly examined in the suitable clinical scenario. Significantly lower sensitization frequency to propolis raises the possibility of a protective effect due to early oral exposure among the Israeli population.

Contact allergy to hydroxyisohexyl 3-cyclohexene carboxaldehyde in Italy: Prevalence, trend, and concordance with fragrance mix II

BACKGROUND

Hydroxyisohexyl 3-cyclohexene carboxaldehyde (HICC), contained in fragrance mix II (FM II), has been recognized as a contact sensitizer since the mid-1990s. After several attempts to reduce its use during the last two decades, HICC was permanently banned from the European market in August 2021.

OBJECTIVES

To assess the prevalence and the time trend of contact allergy to HICC and to investigate the concordance of HICC allergy compared to FM II allergy in an unselected Italian patch test population.

METHODS/PATIENTS

Retrospective analysis on demographics and patch test results of HICC-sensitized and/or FM II-sensitized patients was performed over a 6-year period (2016-2021) at 6 patch test Clinics in Italy.

RESULTS

Among 7266 patients (4942 females, 68.0%, mean age 45.4 ± 20.6 years), 1% (70) resulted positive to HICC and 2.1% (153) to FM II. Clinical relevance was documented in 72.9% (51/70) of HICC positive patients. Among the 169 HICC and/or FM II positive patients, 9.5% had a positive reaction to HICC only, 31.9% to both HICC and FM II, and 58.6% to FM II only. The prevalence trend line of HICC positive reactions showed a decrease from 1.15% (2016) to 0.96% (2021).

CONCLUSIONS

We documented a decreasing trend of HICC allergy in Italy, in line with the data recently reported in literature. Nevertheless, HICC should be maintained in the baseline series to monitor the benefits of its ban from the European market.

Evaluation of pollutants in perfumes, colognes and health effects on the consumer: a systematic review

Cosmetic products, especially perfumes and colognes, are widely used in various communities. However, the use of these products can have side effects on consumers. This article aims to review the relevant literature published up to August 2020 to determine whether perfumes and colognes can affect people's health. Relevant articles were identified through electronic search. A total of 562 articles were selected and finally 37 related articles were included in the study after the screening process. The results of this systematic study showed that phthalates, aldehydes, parabens and aluminum-based salts are the most important contaminants in aromatic products that cause side effects such as allergies, breast cancer, reproductive disorders, especially in males, skin allergies, nervous system damage and migraine headaches for consumers. The incidence of complications in people using these products depends on parameters such as age, gender, race, amount of substance consumed, duration of use and economic status, and regarding the relationship between diseases such as cancer, respiratory disorders and endocrine with common contaminants in aromatic products, incidence of these diseases is probable in consumers which require further research to prove.

Low Prevalence of Fragrance Contact Allergy Among Turkish Population: A 24-Year, Cross-Sectional, Tertiary Single-Center, Retrospective Study

BACKGROUND

Limited data exist on fragrance contact allergy among Turkish population.

OBJECTIVE

The aim of this study was to investigate the frequency and characteristics of fragrance contact allergy in Turkey.

METHODS

A retrospective cohort study was conducted on 2566 patients consecutively patch tested with the European baseline series and additionally with a fragrance series (n = 358) at a tertiary referral center between 1996 and 2019.

RESULTS

One hundred sixty-three patients (6.4%) (male/female, 1.5:1) were sensitized with at least 1 fragrance allergen. Fragrance mix (FM) I was most frequently positive (3.9%), followed by Myroxylon pereirae (3.1%), FM II (2%), and hydroxyisohexyl 3-cyclohexene carboxaldehyde (0.5%), the latter exclusively positive in FM II-positive patients. Among 358 patients patch tested with a fragrance series, positive patch test reactions were observed in 38 patients, including 8 who did not react to baseline fragrance markers. Clinically relevant fragrance allergy was established in 128 patients (78.5%) from nonoccupational (72.4%) and occupational (6.1%) sources.

CONCLUSIONS

The low prevalence, the middle-aged male preponderance, and the predominant involvement of hands were unusual findings. Rose/citrus-flavored perfumes and eau de cologne, which are traditionally preferred in our country, were important elicitors of fragrance contact allergy, especially among middle-aged and older men.

Contact allergy to fragrance mix I and its components in individuals with photocontact allergy to ketoprofen

BACKGROUND

Contact allergy to fragrance mix I (FM I) is over-represented in patients photoallergic to ketoprofen. The prevalence of contact allergy to two components of FM I, cinnamal and cinnamyl alcohol, in ketoprofen-photoallergic patients is higher than in dermatitis patients.

OBJECTIVE

To explore the prevalence of contact allergy to FM I and its individual components in patients with photocontact allergy to ketoprofen, and to compare with a dermatitis and the general population.

METHODS

Data on patch and photopatch tests performed between 2009-2018 were collected. Ketoprofen-photoallergic patients were compared with dermatitis patients and published data on the general population regarding the prevalence and the distribution of contact allergy to FM I and its components.

RESULTS

A higher prevalence of contact allergy to cinnamyl alcohol compared with cinnamal (23.3% vs 10.0%), and eugenol compared with isoeugenol (23.3% vs 6.7%), was observed in ketoprofen-photoallergic patients, while the relationship was the opposite in the dermatitis group (0.7% vs 1.05%; 0.4% vs 0.9%). The overall prevalence of contact allergy to several components of FM I was significantly higher in ketoprofen-photoallergic patients.

CONCLUSIONS

Contact allergy to FM I and many of its components is over-represented in patients photoallergic to ketoprofen compared with dermatitis patients and the general population.

Allergic contact dermatitis to cosmetics: retrospective analysis of a population subjected to patch tests between 2004 and 2017

Background

Cosmetics are part of the daily life of the population, and their use can lead to allergic contact dermatitis.

Objectives

To assess the profile of patients diagnosed with allergic contact dermatitis to cosmetics treated at a referral center for 13 years, as well as the characteristics of the clinical picture and allergens involved.

Methods

This was a retrospective study, with analysis of medical records of patients attended at this service. The individuals included had a diagnostic hypothesis of allergic contact dermatitis to cosmetics and had previously been submitted to epicutaneous tests.

Results

A total of 1405 medical records were analyzed, 403 (28.7%) with suspected allergic contact dermatitis to cosmetics and 232 (16.5%) with confirmed diagnosis. Of these, 208 (89.7%) were women, and the age group most affected was 31 − 60 years. The most common locations were face in 195 cases (25.8%), cervical region in 116 (15.3%), and trunk in 96 (12.6%). The main allergens in the contact tests were toluene-sulfonamide-formaldehyde resin in 69 cases (29.7%), paraphenylenediamine in 54 (26.3%), Kathon CG® in 41 (20.7%), and fragrance-mix 1 in 29 (16.4%). In 154 (66.4%) of the 232 patients with a confirmed diagnosis of allergic contact dermatitis to cosmetics it was possible to specify the cosmetic product responsible for the lesions.

Study limitations

The absence of some allergens considered important in the world as causes of allergic contact dermatitis, which are not readily accessible among us.

Conclusions

The data of the analyzed population (predominance of young women), as well as the location of the lesions (face and cervical area) and the main allergens involved were consistent with those from the world literature.

Allergic Contact Dermatitis to Fragrances

Allergic contact dermatitis to fragrance is common. The prevalence of fragrance allergy in the general population is between 0.7% and 2.6%. In patch-test populations, the positive reaction rate to fragrances ranges from 5% to 11%. The most common fragrance screeners in most baseline series include fragrance mix 1, fragrance mix 2, and Balsam of Peru. The addition of hydroxyisohexyl 3-cyclohexene carboxaldehyde, hydroperoxides of limonene, and hydroperoxides of linalool to screening series can further aid in the diagnosis of fragrance allergy. In the proper clinical setting, supplemental patch testing with an additional fragrance or essential oil series should be considered.

Sensitization to Formaldehyde in Northeastern Italy, 1996 to 2012

BACKGROUND

Formaldehyde is a widely used organic compound, used in several applications (hard thermoset resins, adhesives, disinfectants, tissue fixatives, etc), in its free form or released by formaldehyde releaser products. Its use is under control due to its toxic, carcinogenic, and allergenic properties.

OBJECTIVE

The aim of this study was to investigate the frequency of formaldehyde sensitization, time trend, and correlation to occupations.

METHODS

This study is a cross-sectional study on a population of 23,774 patients tested from 1996 to 2012 in Northeastern Italy.

RESULTS

Frequency of sensitization was 3.3%, without any significant time trend. Hands (39.8% overall) and face (25.6% females, 15.5% males) were mainly involved. We found a trend toward decrease by age in females (3.11% in first quintile [14-26 years], 2.29% in fifth quintile [59-97 years], P < 0.01). On a logistic regression analysis (control group: white-collar workers), we found associations in health care (odds ratio [OR], 1.37; 95% confidence interval [CI], 1.04-1.81), wood (OR, 2.14; 95% CI, 1.30-3.51), and textile (OR, 1.79; 95% CI, 1.14-2.79) sectors and professional drivers (OR, 1.94; 95% CI, 1.05-3.60). We found a high rate of cosensitization to formaldehyde in patients with positive patch test reactions to quaternium-15 (OR, 18.7; 95% CI, 12.6-27.7).

CONCLUSIONS

Sensitization to formaldehyde is relevant in our population, especially in the health care sector, wood and textile industries, and professional drivers. No significant time trend was found.

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.

Skincare products containing low concentrations of formaldehyde detected by the chromotropic acid method cannot be safely used in formaldehyde-allergic patients

BACKGROUND

Formaldehyde is a well-known contact sensitizer. Formaldehyde releasers are widely used preservatives in skincare products. It has been found that formaldehyde at concentrations allowed by the European Cosmetics Directive can cause allergic contact dermatitis. However, we still lack information on whether formaldehyde at low concentrations affects dermatitis in formaldehyde-allergic individuals.

OBJECTIVES

To study the effects of low concentrations of formaldehyde on irritant contact dermatitis in formaldehyde-allergic individuals.

METHODS

Fifteen formaldehyde-allergic individuals and a control group of 12 individuals without contact allergy to formaldehyde and formaldehyde releasers were included in the study. The individuals performed the repeated open application test (ROAT) during 4 weeks with four different moisturizers releasing formaldehyde in concentrations that had been determined as > 40, 20-40, 2·5-10 and 0 p.p.m. by the chromotropic acid (CA) spot test. Dimethyloldimethylhydantoin was used as a formaldehyde releaser in the moisturizers. The ROAT was performed on areas of experimentally induced sodium lauryl sulfate dermatitis. The study was double blind, controlled and randomized.

RESULTS

Nine of the 15 formaldehyde-allergic individuals had reappearance or worsening of dermatitis on the areas that were treated with moisturizers containing formaldehyde. No such reactions were observed in the control group (P < 0·001) or for the moisturizers without formaldehyde in the formaldehyde-allergic individuals (P < 0·001).

CONCLUSIONS

Our results demonstrate that the low concentrations of formaldehyde often found in skincare products by the CA method are sufficient to worsen an existing dermatitis in formaldehyde-allergic individuals.

EAACI position paper for practical patch testing in allergic contact dermatitis in children

INTRODUCTION

Allergic contact dermatitis (ACD) in children appears to be on the increase, and contact sensitization may already begin in infancy. The diagnosis of contact dermatitis requires a careful evaluation of a patient's clinical history, physical examination, and skin testing. Patch testing is the gold standard diagnostic test.

METHODS

Based on consensus, the EAACI Task Force on Allergic Contact Dermatitis in Children produced this document to provide details on clinical aspects, the standardization of patch test methodology, and suggestions for future research in the field.

RESULTS

We provide a baseline list of test allergens to be tested in children with suspected ACD. Additional tests should be performed only on specific indications.

Guidelines for diagnosis, prevention and treatment of hand eczema

The guidelines aim to provide advice on the management of hand eczema (HE), using an evidence- and consensus-based approach. The guidelines consider a systematic Cochrane review on interventions for HE, which is based on a systematic search of the published literature (including hand-searching). In addition to the evidence- and consensus-based recommendation on the treatment of HE, the guidelines cover mainly consensus-based diagnostic aspects and preventive measures (primary and secondary prevention). Treatment recommendations include non-pharmacological interventions, topical, physical and systemic treatments. Topical corticosteroids are recommended as first line treatment in the management of HE, however continuous long-term treatment beyond six weeks only when necessary and under careful me-dical supervision. Alitretinoin is recommended as a second line treatment (relative to topical corticosteroids) for patients with severe chronic HE. Randomized control trials (RCT) are missing for other used systemic treatments and comparison of systemic drugs in “head-to-head” RCTs are needed.The guidelines development group is a working group of the European Society of Contact Dermatitis (ESCD) and has carefully tried to reconcile opposite views, define current optimal practice and provide specific recommendations, and meetings have been chaired by a professional moderator of the AWMF (Arbeitsgemeinschaft der Wis-senschaftlichen Medizinischen Fachgesellschaften; Association of the Scientific Medi-cal Societies in Germany).No financial support was given by any medical company. The guidelines are expected to be valid until December 2017 at the latest.

Fragrance allergic contact dermatitis

Fragrances are a common cause of allergic contact dermatitis in Europe and in North America. They can affect individuals at any age and elicit a spectrum of reactions from contact urticaria to systemic contact dermatitis. Growing recognition of the widespread use of fragrances in modern society has fueled attempts to prevent sensitization through improved allergen identification, labeling, and consumer education. This review provides an overview and update on fragrance allergy. Part 1 discusses the epidemiology and evaluation of suspected fragrance allergy. Part 2 reviews screening methods, emerging fragrance allergens, and management of patients with fragrance contact allergy. This review concludes by examining recent legislation on fragrances and suggesting potential additions to screening series to help prevent and detect fragrance allergy.

Fragrance allergy and quality of life - a case-control study

BACKGROUND

Fragrance ingredients can cause contact allergy, which may affect quality of life (QoL). However, few studies have investigated this topic.

OBJECTIVES

To investigate QoL life among subjects with a fragrance allergy as compared with other eczema patients.

METHODS

A case-control survey was sent to subjects with a positive patch test reaction to a fragrance ingredient/marker (n = 550) and to a control group (n = 1100). It contained questions on eczema and the newly developed fragrance QoL index. Participants had been consecutively patch tested at Gentofte University Hospital (2000-2010). The response rate was 65.7%. Information on patch test data was retrieved from the National Contact Dermatitis Database.

RESULTS

An increase in impairment of QoL was observed in women with fragrance allergy as compared with the control group (p = 0.042), which was not found among men. Several factors played a significant role in impairment of QoL in women: (i) number of fragrance allergies, (ii) severity of the patch test reaction, (iii) age combined with recent diagnosis; and (iv) allergy to specific fragrance ingredients/markers.

CONCLUSION

Fragrance-allergic subjects are just as affected in their QoL as other eczema patients. However, women, and in particular recently diagnosed young women, seem to be more impaired in their QoL than other eczema patients.

Pattern of contact sensitization in patients with and without atopic dermatitis in a hospital-based clinical database

BACKGROUND

Both atopic dermatitis and contact sensitization are common conditions; however, a definite understanding of the relationship between contact sensitization and atopic dermatitis has not been reached.

OBJECTIVES

In this descriptive study, we investigated the differences between positive patch test reactions in patients with and without atopic dermatitis in a patch test cohort, and explored the influence of disease severity.

PATIENTS/MATERIALS/METHODS

Patch test results, information on atopic dermatitis and demographic variables were taken from a database, including all patients patch tested at Bispebjerg and Roskilde Hospitals from January 2009 to January 2013. Severe atopic dermatitis was defined as systemic therapy or hospitalization resulting from atopic dermatitis. All other patients with atopic dermatitis were defined as having mild/moderate disease.

RESULTS

The study included 2221 patients: 293 patients with atopic dermatitis and 1928 without. Forty-one per cent of patients with and 46.2% of patients without atopic dermatitis had at least one positive patch test reaction (p = 0.092). More patients with severe atopic dermatitis than patients with non-severe atopic dermatitis had multiple positive patch test reactions (19.4% versus 10.0%, p = 0.046).

CONCLUSIONS

Overall, we found similar frequencies of positive patch test reactions in patients with and without atopic dermatitis. However, a higher frequency of multiple sensitizations was found in patients with severe atopic dermatitis.