Decreasing trends in methyldibromo glutaronitrile contact allergy – following regulatory intervention

Legislation and Current Practices Concerning Risk Assessment of Skin Sensitizers in the European Union: A Comparative and Survey Study

BACKGROUND

Despite legislation aimed to protect the population against skin sensitization in the European Union (EU), over one quarter of the general population is sensitised to at least one chemical.

OBJECTIVES

To provide an overview and comparison of European legislation concerning skin sensitization. In addition, we gathered the opinions of experts and stakeholders regarding improvements in the legislation and risk assessment process in the EU, to provide suggestions for improvement.

METHODS

Legislation was identified and compared. Four questionnaires were created towards industry, competent authorities and regulators, researchers/clinicians, and non-governmental organisations. The questions concerned the legislation, the risk assessment process, data collection and potential improvements.

RESULTS

Seven areas of legislation were analysed. The legislation was found to be unharmonised, for example, differing modes of restriction and accepted tests for skin sensitization. Approximately 40% of the questionnaire respondents found that the EU legislation and tools were not sufficiently protective. To improve the legislation 83% suggested harmonisation and 68% suggested better data sharing. Other areas were: improved exposure data (78%), better understanding of the skin sensitization mechanism (67%) and non-animal tests (66%).

CONCLUSIONS

Stakeholders had varying confidence towards the protection of European citizens against skin sensitization. Multiple areas for improvement regarding the legislations and the risk assessment process were identified.

High prevalence but no current clinical relevance of methyldibromo glutaronitrile since its ban in Turkey in 2015

BACKGROUND

Regulatory actions significantly reduced methyldibromo glutaronitrile (MDBGN)-induced allergic contact dermatitis (ACD) from cosmetics in Europe. Turkey banned MDBGN in 2015.

OBJECTIVES

To assess sensitization and ACD rates to MDBGN before and after its ban in Turkey.

METHODS

Data from 2653 consecutively patch tested patients between 1996 and 2023 with MDBGN 0.1% pet. (n = 573) or 0.2%-0.3% pet. (n = 1310) or 0.5% pet. (n = 770) were analysed. MDBGN was tested as MDBGN/phenoxyethanol (PE) in 1434 patients.

RESULTS

The sensitization prevalence was 1.7% (45/2653), peaking at 5.3% in 2018 and 2023 with MDBGN 0.3% pet. There was a two-fold male predominance, with patients exclusively ≥20 years old. None of the patients reacted to PE. ACD occurred in 0.7% (19/2653), mainly affecting hands and linked to non-occupational exposure (78.9%), particularly from rinse-off/leave-on cosmetics. The pattern of 'middle-aged men with hand eczema and fragrance allergy' was particularly notable. Occupational ACD was rare (21.1%), occurring mainly in hairdressers from hair gel. Positive reactions with current clinical relevance dropped from 48.3% (1996-2014) to zero after 2015 (p < 0.001).

CONCLUSIONS

The ban effectively reduced MDBGN-induced ACD in Turkey, yet the prevalence of positive patch test reactions remains high, likely due to past exposures or other undisclosed sources. We suggest continued testing of MDBGN in the EBS in Turkey.

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.

TFOS Lifestyle: Impact of cosmetics on the ocular surface

In this report the use of eye cosmetic products and procedures and how this represents a lifestyle challenge that may exacerbate or promote the development of ocular surface and adnexal disease is discussed. Multiple aspects of eye cosmetics are addressed, including their history and market value, psychological and social impacts, possible problems associated with cosmetic ingredients, products, and procedures, and regulations for eye cosmetic use. In addition, a systematic review that critically appraises randomized controlled trial evidence concerning the ocular effects of eyelash growth products is included. The findings of this systematic review highlight the evidence gaps and indicate future directions for research to focus on ocular surface outcomes associated with eyelash growth products.

A systematic review of allergic and irritant contact dermatitis of the vulva: The most important allergens/irritants and the role of patch testing

Vulvar allergic contact dermatitis (vACD) and irritant contact dermatitis (vICD) are common and accompanied by a great burden on the patient's life. We aimed to review the existing literature on vACD and vICD in order to provide a comprehensive reference list of potential vulvar allergens and irritants, as well as to establish the role of patch testing therein. A systematic search was performed in Medline, Embase and Web of Science using a search string based on the PICO-format. The study protocol was registered at PROSPERO (CRD42021239527). Multiple allergens were identified and included metals, topical drugs, fragrances, preservatives, cosmetic constituents and rubber components. Not all positive reactions were, however, considered to be relevant. Patch testing is the primary tool for the identification of the causal allergens. Testing with standard series alone was proven to be insufficient. Little information about irritants was found. In the future, additional series and late readings should be considered in standard practice. Studies on vICD are scarce and further research is necessary. More population-based research should be performed.

Contact dermatitis associated with preservatives: Retrospective analysis of North American Contact Dermatitis Group data, 1994 through 2016

BACKGROUND

Preservatives are often necessary components of commercial products. Large-scale North American studies on preservative allergy are limited.

OBJECTIVE

To evaluate demographics, positive patch test reactions (PPTRs), clinical relevance, and trends for preservatives tested by the North American Contact Dermatitis Group.

METHODS

We conducted a retrospective cross-sectional analysis of North American Contact Dermatitis Group patch testing results of preservatives from 1994 through 2016.

RESULTS

A total of 50,799 patients were tested; 11,338 (22.3%) had a PPTR to at least 1 preservative. The most frequent reactions were to methylisothiazolinone 0.2% aqueous (aq) (12.2%), formaldehyde 2% aq (7.8%), formaldehyde 1% aq (7.8%), quaternium-15 2% petrolatum (pet) (7.7%), and methyldibromo glutaronitrile/phenoxyethanol 2% pet (5.1%). Paraben mix 12% pet (1%), iodopropynyl butylcarbamate 0.1% pet (0.4%), benzyl alcohol 1% pet (0.3%), and phenoxyethanol 1% pet (0.2%) had the lowest PPTRs. Linear regression analysis of preservatives tested showed that only methylchloroisothiazolinone/methylisothiazolinone 0.01% aq (parameter estimate, 0.42; 95% CI, 0.17-0.66; P < .005) had a significant increase in PPTRs over time.

LIMITATIONS

Collected variables are dependent on clinical judgment. Results may be prone to referral selection bias.

CONCLUSIONS

This large North American study provides insight on preservative PPTRs and trends from 1994 through 2016.

Should methyldibromo glutaronitrile continue to be used in the European baseline Series? A REIDAC national cross-sectional study

BACKGROUND

Methyldibromo glutaronitrile (MDBGN) was one of the most frequent and relevant allergens found in patch testing at the beginning of this century. In 2008, this preservative was banned from cosmetics in Europe and ever since the prevalence of contact allergy to MDBGN has progressively decreased. Despite that gradual decline, MDBGN is still patch-tested in most baseline series. This study assessed the frequency of MDBGN sensitization, epidemiological characteristics of allergic patients, and the relevance of positive patch tests in a nationwide Spanish registry (REIDAC).

PATIENTS AND METHODS

We evaluated consecutively patch-tested patients in all participating centres. Using these data, we calculated the proportion of patients with positive patch tests to MDBGN from June 2018 to June 2020 and evaluated the relevance of the positive patch tests.

RESULTS

One hundred and fourteen out of 5072 (2.24 %) tested patients were sensitized to MDBGN. Clinical current relevance was confirmed in only one case.

CONCLUSION

Although the frequency of contact allergy to MDBGN remains high, no clinical significance was found in most of these patients (5072 tests needed to obtain one relevant positive result). The clinical usefulness of this allergen seems weak and its continued inclusion in the European baseline series is questionable.

HIGHLIGHTS

In 2008 methyldibromo glutaronitrile (MDBGN) was banned from cosmetics in Europe and since then, the prevalence of allergy to it has progressively decreased. Nevertheless, it is still being tested in European baseline series. This study assessed the frequency of MDBGN sensitization, epidemiological characteristics of allergic patients as well as the relevance of positive patch tests in a nationwide registry (REIDAC). The frequency of allergy to MDBGN remains high, but no clinical significance was found. Most of these patients are aged >40 years and probably represent historical sensitizations.

Patch Testing to Methyldibromoglutaronitrile/Phenoxyethanol: North American Contact Dermatitis Group Experience, 1994-2018

BACKGROUND

Methyldibromoglutaronitrile/phenoxyethanol (MDBGN/PE) is a broad-spectrum preservative mixture used in consumer and industrial products.

OBJECTIVES

The aims of the study were (1) to characterize the prevalence and clinical relevance of patch test reactions to MDBGN/PE and the epidemiology of positive patients and (2) to determine the frequency of concomitant reactions of MDBGN/PE and its components.

METHODS

This study used a retrospective analysis of cross-sectional data compiled by the North American Contact Dermatitis Group from 1994 to 2018.

RESULTS

Of 55,477 tested patients, 2674 (4.8%) had positive patch test reactions to MDBGN/PE (1.0%-2.5% petrolatum [pet]); most were + (63.3%) or ++ (22.3%). Clinical relevance was considered definite in 3.0% and probable in 19.3% of reactions. Common dermatitis sites included the hands (26.4%), scattered/generalized distribution (24.7%), and the face (18.3%). Patients with a positive reaction to MDBGN/PE and/or MDBGN and/or PE were significantly more likely to be male and older than 40 years and/or had hand dermatitis (P ≤ 0.0033). Positivity to MDBGN/PE 2.0% pet decreased significantly over time (from 6.0% in 1998-2000 to 2.5% in 2017-2018, P < 0.0001). Personal care products were the most common exposure source (53.2%).

CONCLUSIONS

Over time, positivity to MDBGN/PE 2.0% pet decreased significantly from 6.0% (in 1998-2000) to 2.5% (in 2017-2018). The high proportion of weak (63.3%) reactions underscore the need for careful interpretation of patch test sites. Important demographic associations included male sex and age older than 40 years.

Occupational contact dermatitis in blue-collar workers: results from a multicentre study from the Danish Contact Dermatitis Group (2003-2012)

BACKGROUND

Blue-collar workers have a high risk of occupational contact dermatitis, but epidemiological studies are scarce.

OBJECTIVES

To investigate allergic contact dermatitis in blue-collar workers with dermatitis registered by the Danish Contact Dermatitis Group.

METHODS

A retrospective analysis of patch test data from 1471 blue-collar workers and 1471 matched controls tested between 2003 and 2012 was performed. A logistic regression was used to test for associations.

RESULTS

The blue-collar workers often had occupational hand dermatitis (p < 0.001). Atopic dermatitis was less commonly observed among blue-collar workers (19.6%) than among controls (23.9%) (p = 0.005). Allergens with a statistically significant association with the occupational group of blue-collar workers were epoxy resins, methyldibromo glutaronitrile, 2-bromo-2-nitro-1,3-propanediol, potassium dichromate, and methylchloroisothiazolinone (MCI)/methylisothiazolinone (MI). The following occupations were additionally identified as risk factors for contact sensitization to MCI/MI and MI, epoxy resins, and potassium dichromate, respectively: painting, construction work, and tile setting/terrazzo work.

CONCLUSION

Contact allergy is a major problem among blue-collar workers. The data indicate a healthy worker effect among blue-collar workers diagnosed with dermatitis, as blue-collar workers were diagnosed significantly less often with atopic dermatitis than were controls.

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.

Allergic contact dermatitis: epidemiology, molecular mechanisms, in vitro methods and regulatory aspects. Current knowledge assembled at an international workshop at BfR, Germany

Contact allergies are complex diseases, and one of the important challenges for public health and immunology. The German ‘Federal Institute for Risk Assessment’ hosted an ‘International Workshop on Contact Dermatitis’. The scope of the workshop was to discuss new discoveries and developments in the field of contact dermatitis. This included the epidemiology and molecular biology of contact allergy, as well as the development of new in vitro methods. Furthermore, it considered regulatory aspects aiming to reduce exposure to contact sensitisers. An estimated 15–20% of the general population suffers from contact allergy. Workplace exposure, age, sex, use of consumer products and genetic predispositions were identified as the most important risk factors. Research highlights included: advances in understanding of immune responses to contact sensitisers, the importance of autoxidation or enzyme-mediated oxidation for the activation of chemicals, the mechanisms through which hapten-protein conjugates are formed and the development of novel in vitro strategies for the identification of skin-sensitising chemicals. Dendritic cell cultures and structure-activity relationships are being developed to identify potential contact allergens. However, the local lymph node assay (LLNA) presently remains the validated method of choice for hazard identification and characterisation. At the workshop the use of the LLNA for regulatory purposes and for quantitative risk assessment was also discussed.

Contact sensitization in the elderly

Contact dermatitis from irritant and allergic sources is the reason for 6% to 10% of all dermatologic visits with considerable morbidity and economic impact. Allergic contact dermatitis is a T-cell-mediated inflammatory reaction and develops in predisposed individuals as a consequence of environmental exposure to allergens. Aging is correlated with the rate and type of contact sensitization because of "immunosenescence." The number of old people is growing around the world. This contribution reviews the main findings from published epidemiologic studies on contact allergy in elderly populations. In all examined studies, patch testing was performed in patients with cutaneous manifestations possibly related to contact dermatitis; the prevalence of contact dermatitis in the elderly was from 33% to 64%. Establishing the most frequent allergens responsible for allergic contact dermatitis in the elderly is a hard task. The commonest allergens reported were nickel sulfate, fragrance mix, diamino diphenylmethane, lanolin alcohols, paraben mix, Euxyl K400, quinoline mix, and balsam of Peru. We emphasize that allergens surveillance is needed to realize an "elderly series" for having a useful adjunct to contact allergy that may help the treatment of each patient.

[Importance of epidemiologic surveillance in contact dermatitis: Spanish surveillance system on contact allergies]

The high prevalence of contact dermatitis means that this common medical problem has considerable personal, societal, and economic impact. Clinical and epidemiologic research is needed if we are to shed light on the real situation of contact dermatitis in Spain. In this article we will look at epidemiologic research from a practical point of view and analyze the role of the dermatologist in planning and designing studies. The advantages of multicenter studies are discussed, along with the roles of national and international surveillance networks. We present the Spanish Surveillance System on Contact Allergies, which serves as a bridge between Spanish dermatologists and the European Surveillance System on Contact Allergies. The present and future aims of the Spanish network are described.