Contact allergy to metals in adolescents. Nickel release from metal accessories 7 years after the implementation of the EU Nickel Directive in Poland

Heavy metals in contact dermatitis: A review

Contact dermatitis is an inflammatory skin reaction caused by direct contact with chemical substances in the environment and can either be irritant or allergic in nature. The clinical symptoms of contact dermatitis, include local skin rash, itching, redness, swelling, and lesions. Nowadays, 15-20% of people have some degree of contact dermatitis, which can be more or less severe. Immune responses in allergic contact dermatitis (ACD) are due to the effects of cytokines and allergen-specific CD4⁺ and CD8⁺ T cells on the skin. Acids and alkalis such as drain cleaners, plants such as poinsettias, hair colors, and nail polish remover, are all prominent causes of irritant contact dermatitis (ICDs). Heavy metals are metallic elements with a high atomic weight that are hazardous in low quantities and are known to cause dermatitis after systemic or local exposure. Nickel (Ni), chromium (Cr), lead (Pb), and copper (Cu) are among the most common heavy metals used in various industries. Metal allergies may cause ACD and also systemic contact dermatitis (SCD). Contact dermatitis is detected by laboratory tests such as patch testing, lymphocyte stimulation test (LST), and evaluation of cytokine production by primary cultures of peripheral blood mononuclear cells. This article presents an update on the epidemiological and clinical characteristics of ACD and SCD caused by three heavy metals (Cr, Cu, and Pb). Ni is not discussed due to recent coverage. Furthermore, the effects of contact sensitivity to some other heavy metals, such as gold (Au), cobalt (Co), palladium (Pd), and mercury (Hg) are discussed.

Postoperative Excessive Bleeding following Stainless-Steel Crown Placement in Healthy Children with a Suggested Approach for Prevention

Stainless-Steel Crown (SSC) placement is a common treatment in children, usually without significant adverse consequences. The present case series reports six healthy children were admitted to emergency rooms in two medical centers with delayed excessive bleeding from their gingiva, adjacent to newly placed SSCs. The bleeding, in some cases, was so extensive, that it induced vomiting and anxiety, among the children and their parents, and in two cases required surgical suturing. In all six cases, the most probable etiology was a toxic reaction to the released nickel or chromium ions from the SSCs, exacerbated by contact with wounded and bleeding gingiva. Expression of this cytotoxic mode of action, due to metal ions released from SSCs, is not well documented in children. Our aims are to raise awareness of this unique complication and to suggest an approach to minimize and prevent its occurrence. Recommended immediate treatment includes frequent rinsing of the gingiva to wash out released metal ions and decrease their toxic effect. Furthermore, in the following appointments, we recommend using only SSCs previously soaked in water for several weeks, using zirconia crowns, or using Hall's technique when appropriate.

Chitosan self-assembled polymeric nanoparticles for percutaneous delivery of betamethasone in contact dermatitis

OBJECTIVE

The study was performed with an aim to investigate the efficiency of two treatment options in experimental nickel-induced contact dermatitis (CT), with either betamethasone or chitosan cross-linked nano-encapsulated betamethasone lanoline solutions (nano-betamethasone).

METHODS

Male Wistar rats were used. The differences were compared based on lesion visual appearance, skinfold thickness, white blood cell count (WBC), erythrocyte sedimentation rate (ESR), blood serum prooxidant-antioxidant balance (thiobarbituric acid reactive substances, TBARS; supersoxide dismutase, SOD; catalase, KAT), blood cytokine profile (TNF-α, IL-1β, IL-10, and IL-4), and histological examination of affected skin.

RESULTS

All animals treated with nickel sulfate developed CT and systemic inflammatory response on day 12, which only slightly lessened, if left untreated, on day 20. The therapeutic effectiveness of nano-betamethasone was significantly far superior (p < 0.01) compared to betamethasone. Specifically, the visual appearance of lesion severity of betamethasone vs. nano-betamethasone ± SD was 1.82 ± 0.18 vs. 1.17 ± 0.24 points, skinfold thickness-2.68 ± 0.12 vs. 2.12 ± 0.10 mm, ESR-6.38 ± 0.27 vs. 5.12 ± 0.20 mm/h, WBC-8.47 ± 0.28 vs. 7.17 ± 0.24 10⁹/L, TBARS-1.09 ± 0.04 vs. 0.94 ± 0.02 µmol/L, SOD-3.38 ± 0.26 vs. 4.12 ± 0.18 r.u./L, KAT-11.54 ± 0.14 vs. 10.02 ± 0.19 mkatal/L, respectively. The nano-betamethasone formulation was also more effective (p < 0.01) in increasing anti-inflammatory cytokines level, IL-10 (8.96 ± 0.32 vs. 7.54 ± 0.52 pg/mL) and IL-4 (13.16 ± 0.45 vs. 11.43 ± 0.58 pg/mL); and decreasing in pro-inflammatory TNF-α (20.94 ± 2.30 vs. 26.98 ± 1.16 pg/mL) and IL-1β (19.35 ± 1.28 vs. 24.77 ± 1.75 pg/mL), respectively. These findings were also supported with histological examination.

CONCLUSIONS

Nano-betamethasone may be considered as a more successful transcutaneous therapy for managing contact dermatitis compared to ointments consisting of betamethasone in traditional form.

Nickel release from metallic earrings: A survey of the Danish market and validation of the nickel spot test

BACKGROUND

Exposure to nickel-releasing ear-piercing jewellery may explain the persistently high prevalence of nickel allergy in Europe. While nickel release from earrings is regulated, field studies show that the regulation is not always respected. More knowledge is needed regarding the risk of piercing exposure including suitable screening methods.

OBJECTIVE

To examine the proportion of earrings on the Danish market that release more nickel than allowed, and to validate the use of the dimethylglyoxime (DMG) test as a screening tool.

METHODS

A total of 304 earrings were purchased and tested with the DMG test and X-ray fluorescence spectrometry. The level of nickel release was quantified in a selected subsample of 100 earrings by the European reference test EN 1811. The DMG spot test was validated against EN 1811 at different thresholds.

RESULTS

Excessive nickel release according to the European regulation was found in 45 (14.8%) tested earrings. The sensitivity of the DMG test decreased with reduced levels of nickel release (sensitivity of 45.2% at ≥0.2 μg/cm2 /week vs 61.1% at >0.5 μg/cm2 /week).

CONCLUSION

Excessive nickel release is common in earrings on the Danish market. Because of low sensitivity, the DMG test has limited use in screening of earrings for research but may still be used clinically.

Nickel, chromium and cobalt: the relevant allergens in allergic contact dermatitis. Comparative study between two periods: 1995-2002 and 2003-2015

BACKGROUND

Metals are common agents of allergic contact dermatitis, occupational or not, with decreasing incidence over the last years in some countries that have regulated the amount of nickel in objects.

OBJECTIVES

To analyze and compare with previous studies the profile of metal sensitization between 2003-2015.

METHODS

Patients who underwent patch testing between 2003-2015 were evaluated retrospectively regarding the sensitization rates to metals, the associations between them, the relationship with profession and epidemiology.

RESULTS

Of the 1,386 patients tested, 438 (32%) had positive test to some metal, similar results to the 404/1,208 (33%) of the previous study (1995-2002) performed at the same service (p=0.32). The frequency of nickel (77%), cobalt (32%) and chromium (29%) changed slightly (p=0.20). Most cases of sensitization to chromium were related to the occupation (64%), in contrast to nickel and cobalt (p<0.0001). There was a predominance of females among those sensitized to metal in both studies (p=0.63) and the age group of 20-49 years old (p=0.11); the number of fair-skinned individuals increased (p<0.001), as well as the lesions in the cephalic segment (50.5%; p<0.0001) and hands (45%; p<0.0001), which are not the most frequent location anymore. The number of cleaners decreased (39% vs. 59%; p<0.0001), which still lead in front of bricklayers/painters, which increased (14% vs. 9%; p=0.013). The frequency of wet work reduced (65% vs. 81%; p<0.0001).

STUDY LIMITATIONS

The study included a single population group; only patients with positive tests to metals were considered - the others were not evaluated for the possibility of false negatives.

CONCLUSION

The sensitization to metals, occupational or not, has been significant over the last 21 years, with few epidemiological changes.

Allergic contact dermatitis pattern in Kuwait: nickel leads the pack. In-depth analysis of nickel allergy based on the results from a large prospective patch test series report

INTRODUCTION

Contact dermatitis is a relatively common dermatosis reported among several population groups from all around the globe. However, the data from Kuwait is unavailable. Patch tests are essential for the diagnosis of contact sensitization.

AIM

To determine a relative frequency and pattern of sensitizers to different allergens in patients of suspected contact dermatitis in Kuwait and, also to study the role of the commonest sensitizer in detail.

MATERIAL AND METHODS

Patch tests were performed in 2461 consecutive patients with a clinical diagnosis of contact dermatitis seen at our hospital between September 1, 2014 and August 31, 2015. Out of the total of 1381 (56.1%) patients with positive patch test results to at least one allergen, 546 (22.2%) patients with a single positive reaction to nickel only (single largest sensitizer) were selected as the study population for further detailed analysis.

RESULTS

At least one positive patch test reaction was found in 1381 (56.12%) patients. Nickel was found to be the most common sensitizer seen in 546 (40%) patients. The mean age was 37.3 ±13.8 years and the mean duration of disease was 27.3 ±13.8 months. Most (387/546) patients sensitized were females. The forearms/hands and wrists were the most prevalent sites (52.56% of the participants). In 58.91% of women, dermatitis was more often confined to other sites, mostly ears and the neck due to earrings and necklaces. Just more than half of the number (51.09%) of nickel allergic patients were found in the age group of 15-25 years. Hairdressers/beauticians were the most affected group followed by house workers (housewives, cleaners, housekeepers).

CONCLUSIONS

Nickel is the single most common sensitizer found in our patients, and female sex, young age, occupation with long hours of contact to nickel are high risk factors. We recommend that a directive, which limits the release of nickel from products with extended skin contact, be approved in Kuwait.

Metals Are Important Contact Sensitizers: An Experience from Lithuania

Background. Metals are very frequent sensitizers causing contact allergy and allergic contact dermatitis worldwide; up-to-date data based on patch test results has proved useful for the identification of a problem. Objectives. In this retrospective study prevalence of contact allergy to metals (nickel, chromium, palladium, gold, cobalt, and titanium) in Lithuania is analysed. Patients/Methods. Clinical and patch test data of 546 patients patch tested in 2014-2016, in Vilnius University Hospital Santariskiu Klinikos, was analysed and compared with previously published data. Results. Almost third of tested patients (29.56%) were sensitized to nickel. Younger women were more often sensitized to nickel than older ones (36% versus 22.8%, p = 0.0011). Women were significantly more often sensitized to nickel than men (33% versus 6.1%, p < 0.0001). Younger patients were more often sensitized to cobalt (11.6% versus 5.7%, p = 0.0183). Sensitization to cobalt was related to sensitization to nickel (p < 0.0001). Face dermatitis and oral discomfort were related to gold allergy (28% versus 6.9% dermatitis of other parts, p < 0.0001). Older patients were patch test positive to gold(I) sodium thiosulfate statistically significantly more often than younger ones (44.44% versus 21.21%, p = 0.0281). Conclusions. Nickel, gold, cobalt, and chromium are leading metal sensitizers in Lithuania. Cobalt sensitization is often accompanied by sensitization to nickel. Sensitivity rate to palladium and nickel indicates possible cross-reactivity. No sensitization to titanium was found.

Are Females at Greater Risk for Revision Surgery After Hip Resurfacing Arthroplasty With the Articular Surface Replacement Prosthesis?

BACKGROUND

Female patients undergoing hip resurfacing arthroplasties may be at greater risk of revision surgery than males, but it is unclear whether this is related to sex or other factors. We focused our analysis on data from a prospective multicenter cohort study monitoring the ASR(TM) hip resurfacing arthroplasty prosthesis on the potential association of sex on patient-reported outcome measures (PROMs), metal ion levels, revision surgery, and presence of adverse local tissue reaction. As thousands of patients with the ASR(TM) prosthesis are still undergoing followup it is critical to optimize the protocol for monitoring these patients.

QUESTIONS/PURPOSES

We wished (1) to assess the associations between sex and implant survival, and adverse local tissue reaction; and (2) to report the differences between sexes in metal ion levels and patient-reported outcome measures.

METHODS

One thousand two hundred fifty-two patients (1390 hips) who underwent hip resurfacing arthroplasty with implantation of the ASR(TM) prosthesis from April 2003 to July 2010 were eligible for enrollment in a multicenter followup study of the ASR(TM) Hip Resurfacing System after the voluntary recall of this device was initiated by DePuy in 2010. Nine hundred seventy patients (1098 hips) were enrolled at a mean of 7 years after surgery, with a mean followup of 2 years (range, 1-3.5 years). Nine hundred fifty-eight patients (1084 hips) met the inclusion criteria: ability to provide informed consent, complete PROMs, and continued routine followup. A subset of patients (150 patients, 171 hips), who all were from one center, with annual metal artifact reduction sequence MRI were analyzed. Ninety-three percent of patients from this center had routine MRI performed. The EuroQoL (EQ-5D), Harris hip score (HHS), University of California Los Angeles (UCLA) activity score, VAS pain, radiographs, patient and surgery details, and blood cobalt and chromium levels were obtained. Cox regression analysis was conducted to identify factors associated with implant survival, using any revision as the end point, and presence of adverse local tissue reaction.

RESULTS

In patients who had unilateral surgery, the only variable found to be associated with revision surgery was HHS (hazard ratio [HR], 0.96; 95% CI, 0.94-0.97; p < 0.001). In patients who had bilateral surgery, only HHS (HR, 0.93; 95% CI, 0.90-0.97; p < 0.001) and cobalt level (HR, 1.02; 95% CI, 1.01-1.03; p < 0.001) were associated with risk for revision. In patients with metal artifact reduction sequence MRI, the only variable found to be associated with presence of adverse local tissue reaction was cobalt level (HR, 1.06; 95% CI, 1.02-1.10; p = 0.001). Cobalt and chromium concentrations were greater in female patients than in male patients (cobalt, median 1.89 versus median 1.12 parts per billion [ppb], p < 0.001; chromium, median 2.03 versus median 1.17 ppb, p < 0.001). Slight differences were observed between males and females in HHS (males median 96 versus females median 94, p < 0.001) and UCLA scores (median 8 versus median 6, p < 0.001); however, there was no difference between sexes for VAS pain (median 0.5 versus median 0.5, p = 0.405). Differences were identified between males and females in the distribution of EQ-5D scores, yet the medians were the same (median 1.0 versus median 1.0, p < 0.001).

CONCLUSIONS

Male and female patients who had hip resurfacing arthroplasty with implantation of the ASR(TM) prosthesis should be followed with equal vigilance as both are at similar risk of revision surgery and adverse local tissue reaction. Metal ion levels and HHS should be obtained at followup to monitor for risk of revision and as a screening tool for MRI. Further research is necessary to evaluate if these relationships persist in patients with other metal-on-metal prostheses.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Nickel and cobalt release from jewellery and metal clothing items in Korea

BACKGROUND

In Korea, the prevalence of nickel allergy has shown a sharply increasing trend. Cobalt contact allergy is often associated with concomitant reactions to nickel, and is more common in Korea than in western countries.

OBJECTIVE

The aim of the present study was to investigate the prevalence of items that release nickel and cobalt on the Korean market.

MATERIALS AND METHODS

A total of 471 items that included 193 branded jewellery, 202 non-branded jewellery and 76 metal clothing items were sampled and studied with a dimethylglyoxime (DMG) test and a cobalt spot test to detect nickel and cobalt release, respectively.

RESULTS

Nickel release was detected in 47.8% of the tested items. The positive rates in the DMG test were 12.4% for the branded jewellery, 70.8% for the non-branded jewellery, and 76.3% for the metal clothing items. Cobalt release was found in 6.2% of items. Among the types of jewellery, belts and hair pins showed higher positive rates in both the DMG test and the cobalt spot test.

CONCLUSION

Our study shows that the prevalence of items that release nickel or cobalt among jewellery and metal clothing items is high in Korea.