Allergens responsible for allergic contact dermatitis among children: a systematic review and meta-analysis

Systemic Immune Factors and Risk of Allergic Contact Dermatitis: A Bidirectional Mendelian Randomization Study

Skin inflammation and immune regulation have been suggested to be associated with allergic contact dermatitis (ACD) progression, but whether the system's immune regulation is a cause or a potential mechanism is still unknown. This study aims to assess the upstream and downstream of systemic immune factors on ACD within a bidirectional Mendelian-randomization design. A bidirectional two-sample MR analysis was employed to implement the results from genome-wide association studies for 52 system immune factors and ACD. Genetic associations with systemic immune factors and ACD were obtained from the IEU Open GWAS project database. The inverse-variance weighted (IVW) method was adopted as the primary MR analysis, MR-Egger, weighted median, MR-pleiotropy residual sum, and outlier (MR-PRESSO) was also used as the sensitivity analyses. Only Tumor necrosis factor ligand superfamily member 11 (TNFS11) from among 52 systemic immune factors was associated with a protective effect of ACD. However, ACD was associated with a decrease in Interleukin-9 (IL9) and an increase in C-X-C motif chemokine 1 (GROα), Tumor necrosis factor ligand superfamily member 10 (TRAIL), C4, and complement factor B of the assessed systemic immune factors. This study identified TNFS11 as the upstream regulator and IL9, GROα, TRAIL, C4, and complement factor B as the downstream regulator of ACD, providing opportunities for new therapeutic exploitation of ACD. Nonetheless, these associations of systemic immune factors need to be verified in vivo.

The Contact Sensitivity of Turkish Children and Adolescents to European Baseline Series Allergens between 2013 and 2023

INTRODUCTION

Increasing the numbers of patch testing in suspected children increases the rate of diagnosis of allergic contact dermatitis and the identification of clinically relevant allergens.

OBJECTIVE

The aim of this study was to identify the most frequently observed allergens among Turkish children and adolescents patch-tested in 2013-2023.

METHODS

The patch test results of 160 patients (age ≤18) were analyzed retrospectively. The frequency of contact allergens and distribution of positive results in terms of sex, age group (children and adolescents), and the presence of atopic dermatitis (AD) were identified.

RESULTS

Forty-nine patients (30.6%) (34 girls and 15 boys) exhibited positive patch test reactions to a minimum of one allergen, and contact sensitivity was statistically significantly higher in girls (P=0.034). The five most frequent allergens were nickel sulfate (10.6%), MCI/MI (8.1%), cobalt chloride (5.6%), p-phenylenediamine (PPD) (5%), and MI (3.5%). No significant association was observed between patch test positivity and age groups (P>.05). Nickel sulfate sensitivity was significantly higher in girls than in boys (P=.043). A positive reaction was detected in 31.3% of patients with AD and in 33.7% of those without (P>.05), and a statistically significant relationship was observed between contact sensitivity to fragrance allergens and AD (P=.046).

CONCLUSION

Metals and preservatives represent the most frequent allergens in Turkish children and adolescents. Metal sensitivity is expected to decrease as legislation is enforced. Regulatory measures are now required to reduce MI and MCI/MI contact allergy in Turkey.

Amended Safety Assessment of Persulfates as Used in Cosmetics

The Expert Panel for Cosmetic Ingredient Safety (Panel) reassessed the safety of 3 persulfate ingredients, which function as oxidizing agents in cosmetic products. The Panel reviewed relevant data relating to the safety of these ingredients and concluded that Ammonium, Potassium, and Sodium Persulfate are safe as used as oxidizing agents in hair colorants and hair lighteners designed for brief discontinuous use followed by thorough rinsing from the hair and skin. The Panel also concluded that the available data are insufficient for determining the safety of these persulfates in leave-on products and dentifrices.

Pediatric patch testing in a multi-ethnic Asian population: A retrospective review

BACKGROUND

Pediatric allergic contact dermatitis (ACD) is increasingly prevalent. Patch testing is the gold-standard diagnostic investigation. The aims of our study were to describe the clinical profile of pediatric patients with ACD in a multi-ethnic Asian population and identify the common contact allergens.

METHODS

This was a retrospective study involving children and adolescents aged 16 years or younger with clinically suspected ACD who underwent patch testing between January 2007 and March 2020 at two institutions in Singapore. Information pertaining to their demographics, atopy history, clinical presentation, and patch test results was analyzed.

RESULTS

A total of 252 patients were included. The mean age was 10.9 years (1.0-16.7 years). The majority were Chinese (79.8%) and girls (57.5%). Many (66.3%) had atopic dermatitis (AD), which was mild. The most common presentation was an acral eczematous rash. The sensitization rate was 50.0%. The most frequent reactions were to nickel sulfate (49.2%) and fragrance mix (19.1%). The overall rate of relevant positive patch tests was 72.5%. Patients with AD were less likely to have a reaction to fragrance mix (p = .019) and more likely to have a reaction to disperse blue (p = .041). Compared to younger children, adolescents were less likely to have a positive patch test (p = .008). Indians were also less likely to have a positive reaction (p = .004).

CONCLUSION

Metals and fragrances were the most common allergens causing childhood ACD in Singapore. Patients with AD were less likely to be sensitized to fragrances and more likely to be sensitized to disperse blue dye.

Global implementation of the world health organization's International Classification of Diseases (ICD)-11: The allergic and hypersensitivity conditions model

The International Classification of Diseases (ICD) provides a common language for use worldwide as a diagnostic and classification tool for epidemiology, clinical purposes and health management. Since its first edition, the ICD has maintained a framework distributing conditions according to topography, with the result that some complex conditions, such as allergies and hypersensitivity disorders (A/H) including anaphylaxis, have been poorly represented. The change in hierarchy in ICD-11 permitted the construction of the pioneer section addressed to A/H, which may result in more accurate mortality and morbidity statistics, including more accurate accounting for mortality due to anaphylaxis, strengthen classification, terminology and definitions. The ICD-11 was presented and adopted by the 72nd World Health Assembly in May 2019, and the implementation is ongoing worldwide. We here present the outcomes from an online survey undertaken to reach out the allergy community worldwide in order to peer review the terminology, classification and definitions of A/H introduced into ICD-11 and to support their global implementation. Data are presented here for 406 respondents from 74 countries. All of the subsections of the new A/H section of the ICD-11 had been considered with good accuracy by the majority of respondents. We believe that, in addition to help during the implementation phase, all the comments provided will help to improve the A/H classification and to increase awareness by different disciplines of what actions are needed to ensure more accurate epidemiological data and better clinical management of A/H patients.

Allergic contact dermatitis in children and proposal for an Australian Paediatric Baseline Series

BACKGROUND

Allergic contact dermatitis (ACD) is an increasingly common diagnosis in children. The objectives of this study were to review our experience with ACD in children in tertiary settings, to ascertain the spectrum of allergens in this population and to subsequently propose the first Australian Paediatric Baseline Series for patch testing.

METHODS

We conducted a retrospective analysis of patch test data from 1993 to 2017 from two tertiary referral patch-testing centres in Melbourne, Victoria.

RESULTS

A total of 511 children were patch tested during the study period. Of these, 58.3% (298/511) of children tested had a positive patch test, and 65.1% (194/298, or 38.0% of the total) had a relevant positive patch test. The most common relevant patch test reactions were fragrance mix, methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) and methylisothiazolinone (MI), Myroxylon pereirae, nickel sulphate, and colophonium.

CONCLUSION

Allergic contact dermatitis is not uncommon in children, and patch testing should be considered in children with suspected ACD or with recalcitrant atopic dermatitis. Based on our experience over 25 years, we propose the first Australian Paediatric Baseline Series.

Contact Allergy in Children with Atopic Dermatitis: A Retrospective Study

Background:

The relationship between atopic dermatitis and allergic contact dermatitis is frequently debated, particularly in children. The impaired skin barrier of atopic subjects can facilitate the penetration of exogenous agents and its mutations in the filaggrin gene might be implicated in an increased risk to develop contact dermatitis. Moreover, atopic children are protractedly exposed to chemical substances contained in skin care products from an early age.

Patients And Methods:

The aim of this retrospective study is to determine if atopic children are more prone to allergic contact dermatitis and which substances are more frequently related to this disease. From 2014 to 2016, a total of 268 children under 14 years with a history of eczematous dermatitis, of whom 141 (52.6%) were affected, and 127 (47.4%) were not affected by AD, underwent patch testing with the baseline S.I.D.A.P.A standard series.

Results:

Based on the results of our study, the prevalence of contact allergy in atopic children is comparable to that noted in non-atopic children. The most frequent causes of contact allergy in children are fragrances, and their prevalence is significantly higher in atopic children (19.9%) than in non-atopic ones, (11.8%; p < .05).

Conclusion:

Our study highlights the importance of patch testing in atopic children for continuously monitoring the trends and changes of contact allergies that are a common disease and is even significantly increasing for some allergens, as fragrances. We may speculate that the protracted use of skincare products, associated with the impaired skin barrier of atopic children, enhances the risk of sensitization to the ingredients of these products.

Patch testing in Israeli children with suspected allergic contact dermatitis: A retrospective study and literature review

BACKGROUND/OBJECTIVES

Childhood allergic contact dermatitis is recognized as a significant clinical problem. The objective was to evaluate the rate of positive patch tests in Israeli children with clinically suspected allergic contact dermatitis, identify possible sex and age differences, compare results with those in Israeli adults, and review pediatric studies in the literature.

METHODS

The study sample included 343 children and adolescents (197 female, 146 male; 1-18 years of age, mean age 11.8 years) with clinically suspected allergic contact dermatitis who underwent patch testing with a standard pediatric series of 23 allergens at a tertiary medical center from 1999 to 2012. Data on clinical characteristics and test results were collected retrospectively from the medical files.

RESULTS

Ninety-eight subjects (28.6%) (75 girls [38.1%], 23 boys [15.8%]) had at least one positive reaction. The most frequent reactions were to nickel sulfate, followed by potassium dichromate and cobalt chloride. Nickel sulfate sensitivity was more common in girls, especially those younger than 3 years and older than 12 years. The prevalence of contact sensitization was similar in subjects with and without atopic dermatitis (50% and 51%, respectively).

CONCLUSION

Nickel is the most common allergen in Israeli children, especially girls. Patch testing should be performed in children with clinically suspected allergic contact dermatitis regardless of atopic background.

Patch-test results in children and adolescents: systematic review of a 15-year period

The number of studies on patch-test results in children and adolescents has gradually increased in recent years, thus stimulating reviews. This paper is a systematic review of a 15-year period devoted to studying the issue. Variations pertaining to the number and age groups of tested children and/or adolescents, the number of subjects with atopy/atopic dermatitis history, the quantity, type and concentrations of the tested substances, the test technique and type of data regarding clinical relevance, must all be considered in evaluating these studies, as they make it harder to formulate conclusions. The most common allergens in children were nickel, thimerosal, cobalt, fragrance, lanolin and neomycin. In adolescents, they were nickel, thimerosal, cobalt, fragrance, potassium dichromate, and Myroxylon pereirae. Knowledge of this matter aids health professionals in planning preventive programs aimed at improving children's quality of life and ensuring that their future prospects are not undermined.

Dissemination of definitions and concepts of allergic and hypersensitivity conditions

BACKGROUND

Allergy and hypersensitivity can affect people of any age and manifest with problems in a range of organ systems. Moreover, they can have a significant impact on the quality of life of patients and their families. Although once rare, there is presently an epidemic of allergic disorders with associated considerable societal consequences. Our understanding of the pathophysiology of these disorders has changed substantially over the last 20 years. In the light of these developments, the Joint Allergy Academies have made concerted efforts to ensure that these are reflected in the current definitions and concepts used in clinical allergy and to ensure these are reflected in the forthcoming International Classification of Diseases-11 (ICD-11).

OBJECTIVE

In this review, we seek to provide an update on the current definitions and concepts in relation to allergic disorders.

RESULTS

Once the new section has been built in the ICD-11 to address allergic and hypersensitivity conditions, we have been moving actions to try to support awareness by disseminating updated concepts in the field. Aligned with the ICD and the WAO philosophy of being global, this document presents fundamental and broad allergy concepts to strengthen the understanding by different health professionals worldwide, besides to support the formation of in training students.

CONCLUSION

This current review intends to be accepted and used universally by all health professionals involved in diseases' classification and coding and, therefore, contribute to improve care and outcomes in this increasing sub-section of the world's population.

Supporting the validation of the new allergic and hypersensitivity conditions section of the World Health Organization International Classification of Diseases-11

Background

The new International Classification of Diseases (ICD)-11 "Allergic and hypersensitivity conditions" section has been constructed as a result of a detailed and careful action plan based on scientific evidences for the necessity of changes and collaboration with the World Health Organization (WHO) ICD-11 revision governance. All the efforts are being acknowledged by the Joint Allergy Academies.

Objective

Considering the new classification model addressed to the allergic and hypersensitivity conditions and following the ICD WHO agenda, we believe it is the appropriate time to start supporting the validation process in collaboration with the WHO ICD governance.

Methods

We conducted a mapping of ICD-10 allergic and hypersensitivity conditions in the ICD-11 beta phase structure and categorized the conditions as fitting by "precoordination," "postcoordination," "indexed to the ICD-11 Foundation," "no code fit properly" or "no correspondence" in the ICD-11.

Results

From overall 125 ICD-10 entities spread in 6 chapters, 57.6% were able to be precoordinated, 4% postcoordinated, 12% indexed to the Foundation, 9.6% had no code fitting properly and 18.6% had no correspondence in the ICD-11 framework.

Conclusion

We have been able to demonstrate that 83.2% of the ICD-10 allergic and hypersensitivity conditions could be captured by the current ICD-11 beta draft framework. We strongly believe that our findings constitute a key step forward for a softer transition of the ICD-10 allergic and hypersensitivity conditions to the ICD-11, supporting the WHO in this process as well as strengthening the visibility of the Allergy specialty and ensuring quality management of allergic patients.

The "Jewelry Addict": Allergic Contact Dermatitis from Repetitive Multiple Children's Jewelry Exposures

A 9-year-old girl with atopic dermatitis developed persistent plaques on the lips, hands, and fingers that were unresponsive to topical steroids. Her mother reported that she was "addicted" to costume jewelry and developed rashes in reaction to a number of adornments, ranging from rubber bracelets to costume metal jewelry and belt buckles. A careful history of jewelry exposures was taken and patch testing was performed to identify allergenic sources. Patch testing revealed allergy to nickel, gold, and thiuram mix. The case illustrates the importance of investigating a range of different types of allergens when evaluating for jewelry sensitivity in children with frequent use of accessories, including rubber jewelry, plastics, dyed yarns, beads, metals, and ceramics. This article provides an overview of jewelry allergies and the potential allergens requiring screening.

Publication bias in dermatology systematic reviews and meta-analyses

Systematic reviews and meta-analyses in dermatology provide high-level evidence for clinicians and policy makers that influence clinical decision making and treatment guidelines. One methodological problem with systematic reviews is the under representation of unpublished studies. This problem is due in part to publication bias. Omission of statistically non-significant data from meta-analyses may result in overestimation of treatment effect sizes which may lead to clinical consequences. Our goal was to assess whether systematic reviewers in dermatology evaluate and report publication bias. Further, we wanted to conduct our own evaluation of publication bias on meta-analyses that failed to do so. Our study considered systematic reviews and meta-analyses from ten dermatology journals from 2006 to 2016. A PubMed search was conducted, and all full-text articles that met our inclusion criteria were retrieved and coded by the primary author. 293 articles were included in our analysis. Additionally, we formally evaluated publication bias in meta-analyses that failed to do so using trim and fill and cumulative meta-analysis by precision methods. Publication bias was mentioned in 107 articles (36.5%) and was formally evaluated in 64 articles (21.8%). Visual inspection of a funnel plot was the most common method of evaluating publication bias. Publication bias was present in 45 articles (15.3%), not present in 57 articles (19.5%) and not determined in 191 articles (65.2%). Using the trim and fill method, 7 meta-analyses (33.33%) showed evidence of publication bias. Although the trim and fill method only found evidence of publication bias in 7 meta-analyses, the cumulative meta-analysis by precision method found evidence of publication bias in 15 meta-analyses (71.4%). Many of the reviews in our study did not mention or evaluate publication bias. Further, of the 42 articles that stated following PRISMA reporting guidelines, 19 (45.2%) evaluated for publication bias. In comparison to other studies, we found that systematic reviews in dermatology were less likely to evaluate for publication bias. Evaluating and reporting the likelihood of publication bias should be standard practice in systematic reviews when appropriate.

Constructing a classification of hypersensitivity/allergic diseases for ICD-11 by crowdsourcing the allergist community

The global allergy community strongly believes that the 11th revision of the International Classification of Diseases (ICD-11) offers a unique opportunity to improve the classification and coding of hypersensitivity/allergic diseases via inclusion of a specific chapter dedicated to this disease area to facilitate epidemiological studies, as well as to evaluate the true size of the allergy epidemic. In this context, an international collaboration has decided to revise the classification of hypersensitivity/allergic diseases and to validate it for ICD-11 by crowdsourcing the allergist community. After careful comparison between ICD-10 and 11 beta phase linearization codes, we identified gaps and trade-offs allowing us to construct a classification proposal, which was sent to the European Academy of Allergy and Clinical Immunology (EAACI) sections, interest groups, executive committee as well as the World Allergy Organization (WAO), and American Academy of Allergy Asthma and Immunology (AAAAI) leaderships. The crowdsourcing process produced comments from 50 of 171 members contacted by e-mail. The classification proposal has also been discussed at face-to-face meetings with experts of EAACI sections and interest groups and presented in a number of business meetings during the 2014 EAACI annual congress in Copenhagen. As a result, a high-level complex structure of classification for hypersensitivity/allergic diseases has been constructed. The model proposed has been presented to the WHO groups in charge of the ICD revision. The international collaboration of allergy experts appreciates bilateral discussion and aims to get endorsement of their proposals for the final ICD-11.

Categorization of allergic disorders in the new World Health Organization International Classification of Diseases

BACKGROUND

Although efforts to improve the classification of hypersensitivity/allergic diseases have been made, they have not been considered a top-level category in the International Classification of Diseases (ICD)-10 and still are not in the ICD-11 beta phase linearization. ICD-10 is the most used classification system by the allergy community worldwide but it is not considered as appropriate for clinical practice. The Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) on the other hand contains a tightly integrated classification of hypersensitivity/allergic disorders based on the EAACI/WAO nomenclature and the World Health Organization (WHO) may plan to align ICD-11 with SNOMED CT so that they share a common ontological basis.

METHODS

With the aim of actively supporting the ongoing ICD-11 revision and the optimal practice of Allergology, we performed a careful comparison of ICD-10 and 11 beta phase linearization codes to identify gaps, areas of regression in allergy coding and possibly reach solutions, in collaboration with committees in charge of the ICD-11 revision.

RESULTS

We have found a significant degree of misclassification of terms in the allergy-related hierarchies. This stems not only from unclear definitions of these conditions but also the use of common names that falsely imply allergy. The lack of understanding of the immune mechanisms underlying some of the conditions contributes to the difficulty in classification.

CONCLUSIONS

More than providing data to support specific changes into the ongoing linearization, these results highlight the need for either a new chapter entitled Hypersensitivity/Allergic Disorders as in SNOMED CT or a high level structure in the Immunology chapter in order to make classification more appropriate and usable.

Allergic contact dermatitis in children: which factors are relevant? (review of the literature)

Allergic contact dermatitis (ACD) in children is increasing. Sensitization to contact allergens can start in early infancy. The epidermal barrier is crucial for the development of sensitization and elicitation of ACD. Factors that may influence the onset of sensitization in children are atopic dermatitis, skin barrier defects and intense or repetitive contact with allergens. Topical treatment of ACD is associated with cutaneous sensitization, although the prevalence is not high. ACD because of haptens in shoes or shin guards should be considered in cases of persistent foot eruptions or sharply defined dermatitis on the lower legs. Clinical polymorphism of contact dermatitis to clothing may cause difficulties in diagnosing textile dermatitis. Toys are another potentially source of hapten exposure in children, especially from toy-cosmetic products such as perfumes, lipstick and eye shadow. The most frequent contact allergens in children are metals, fragrances, preservatives, neomycin, rubber chemicals and more recently also colourings. It is very important to remember that ACD in young children is not rare, and should always be considered when children with recalcitrant eczema are encountered. Children should be patch-tested with a selection of allergens having the highest proportion of positive, relevant patch test reactions. The allergen exposure pattern differs between age groups and adolescents may also be exposed to occupational allergens. The purpose of this review is to alert the paediatrician and dermatologist of the frequency of ACD in young children and of the importance of performing patch tests in every case of chronic recurrent or therapy-resistant eczema in children.

Current strategies in treating severe contact dermatitis in pediatric patients

Allergic contact dermatitis in children is underdiagnosed and undertreated, and its incidence is increasing. Appropriate history taking and the suspicion for allergic contact dermatitis is essential, and patch testing remains the gold standard in diagnosis. Avoidance of the offending allergen, once identified, is the first goal of treatment. Medical therapies include topical corticosteroid and topical immunomodulators. In severe cases, oral corticosteroids or immunomodulators are utilized, although prospective randomized trials for the treatment of this disease in children are lacking. A PubMed literature search was performed to identify publications on allergic contact dermatitis in the pediatric population with the keywords: dermatitis, children, allergic contact dermatitis, pediatrics, contact hypersensitivity, contact allergy, treatment, and management. This review will address the major principles behind the diagnosis and management of this disease in the pediatric population, and highlight useful strategies that may result in improved treatment of this condition.