Current patch test results with the European baseline series and extensions to it from the ‘European Surveillance System on Contact Allergy’ network, 2007-2008

The sesquiterpene lactone mix: A review of past, present and future aspects

The sesquiterpene lactones (SLs) are secondary plant metabolites, which are widespread in the Compositae/Asteraceae plant family. The first SLs were detected more than 100 years ago, and allergic contact dermatitis from Compositae has been reported since the beginning of the 1900s, but it was not until the late 1960s and early 1970s that a collaboration between dermatologists, chemists and botanists led to the detection of SLs as the main allergens of Compositae plants. In the 1980s, the SL mix, consisting of equimolar amounts of alantolactone, costunolide and dehydrocostus lactone, was developed as a screening agent for Compositae sensitisation. Today, after inclusion of SL mix in the baseline series, the mean prevalence of reactions in Europe is around 1%, and in North America 0.8%. In countries outside Europe and North America, the prevalence ranges between 0% and 10.7%. The detection rate of SL mix is lower than that of some plant extracts, and ideally, SL mix should be supplemented with a mix of SLs from locally prevalent allergenic plants. The prevalence of positive reactions to SL mix suggests continued baseline testing in most European countries, North America, New Zealand, Australia and probably some Chinese centres.

Patch testing with the European baseline series and 10 added allergens: Single-centre study of 748 patients

BACKGROUND

The European baseline series (EBS) of contact allergens is subject to change. An allergen is considered for inclusion when routine patch testing of patients with suspected contact dermatitis results in ≥0.5% prevalence rate.

OBJECTIVES

We aimed to determine the frequency of sensitizations to 30 EBS allergens and 10 locally added allergens. Additionally, we assessed the strength and evolution of reactions to all tested allergens and co-reactivity of additional allergens.

METHODS

Patch testing with our baseline series of 40 allergens was done in 748 consecutive adults. Tests were applied to the upper back and removed by patients after 48 h. Readings were done on Day 3 (D3) and D6 or D7 (D6/7). Positive reactions fulfilled the criteria of at least one plus (+) reaction. A retrospective analysis was done.

RESULTS

Eight allergens not listed in the EBS had ≥0.5% prevalence rate (i.e., cocamidopropyl betaine, thiomersal, disperse blue mix 106/124, 2-bromo-2-nitropropane-1,3-diol, diazolidinyl urea, propylene glycol, Compositae mix II and dexamethasone-21-phosphate), and 16.6% of positive reactions would have been missed without D6/7 readings.

CONCLUSION

We propose further studies to evaluate whether cocamidopropyl betaine, disperse blue mix 106/124, 2-bromo-2-nitropropane-1,3-diol, diazolidinyl urea and Compositae mix II need to be added to the EBS.

Determination of Heavy Metals in Hair Dye Sale in Iranian Market: Dermal Sensitivity and Carcinogenicity Assessment

Despite the high consumption of cosmetics especially hair dyes in Iran, limited studies have measured human exposure to heavy metals in these products. Therefore, due to the sensitivity of the issue from a health perspective, this study was performed for the purpose of dermal risk assessment of heavy metals in different brands of hair dyes in Kashan region. The present study is an analytical-observational study. In this study, 36 samples of hair dyes from four best-selling brands in Kashan market (Iran) were selected; then the concentration of lead, cadmium, nickel, chrome, and cobalt was measured by inductively coupled plasma optical emission spectrometry (ICP-OES) and reported as μg g^-1 of dry weight; and finally, a health risk assessment was performed. The heavy metal concentrations in the hair dye samples were 1.825, 0.525, 48.15, 2.975, and 0.575 μg g^-1 for Pb, Cd, Cr, Ni, and Co respectively that were lower than the permissible limit. Both of HI and LCR were below of 1 and 10^-6 that indicated heavy metal in this study had not probable non-carcinogenic and carcinogenic risks for the consumers of these products. An exposure-based sensitization Quantitative Risk Assessment determined an absence of skin-sensitizing potential. However, Cr, Ni, and Co were found at concentrations above the allergenic limit of 5 μg g^-1. According to the results, although due to low concentrations of toxic metals, there is a low level of exposure to heavy metals in hair dye users, but can cause potential health damage to users.

Allergic contact dermatitis to rubber accelerators in protective gloves: Problems, challenges, and solutions for occupational skin protection

Protective gloves are an elementary component of personal protective equipment in many occupations and are intended to protect the hands from various hazards (e.g., wetness, chemicals, mechanical forces, or thermal stress). This is particularly important when other occupational safety measures (e.g., technical-organizational measures) cannot be implemented or are insufficient. However, it is not uncommon for protective gloves themselves to become a problem, as some of their ingredients (e.g., rubber accelerators) can cause allergic reactions. Accelerators in rubber gloves include thiurams, dithiocarbamates, thiazoles, guanidines, and thioureas. If no alternative means of protection are available, this may even result in abandoning the profession. This article is about rubber accelerators, which are often contained in protective gloves made of different rubber materials (e.g., natural rubber (latex) and nitrile rubber) and may cause delayed-type allergies, as well as related challenges, problems, and solutions for occupational skin protection.

Cobalt and lead concentrations in cosmetic products sold at local markets in Saudi Arabia

Cosmetics are products that can be used on the human body for cleaning, beautification or enhancing perceived attractiveness. Cosmetics may contain a variety of heavy metals such as cobalt (Co) and lead (Pb), which at high concentrations may pose adverse effects on human health. This study focuses to measure the concentration of heavy metals (Co and Pb) in some cosmetic samples of four types (foundation, skin lighteners, kajal (kohl) and lawsone (henna)) available at local markets in Saudi Arabia. The total number of all cosmetic samples understudy was 41. The samples were analysed using atomic absorption spectroscopy to measure the content of Co and Pb. Quality control of the data was performed using Standard Reference Materials [IAEA-V-10] hay powder. For all cosmetic types and qualities combined, the Co concentration range was determined to be 21.14 ± 3.70-144.91 ± 2.27 μg/g and the Pb range 0.75 ± 0.00-10.60 ± 1.24 μg/g. The Co concentration in all cosmetic types understudy was higher than the recommended level. Pb concentration was within the range recommended by the United States Food and Drug Administration in all types of cosmetics except for kohl, for which 22 % of the samples contained concentrations higher than the permissible limit. The findings of this study call for immediate and ongoing testing to monitor the concentrations of toxic metals in cosmetic products used in Saudi Arabia to ensure that established limits are respected and thereby protect consumer health.

Experimental Calculations of Metals Content in Skin-Whitening Creams and Theoretical Investigation for Their Biological Effect Against Tyrosinase Enzyme

The demand for skin-whitening creams (SWCs) has increased rapidly worldwide due to sharp rise in product advertisements in the media and the growing awareness. Metals are present either as impurities or added intentionally in creams and may have toxic effects on users. The present study was carried out to determine the content of metals such as mercury (Hg), cadmium (Cd), lead (Pb), arsenic (As), chromium (Cr), nickel (Ni), cobalt (Co), copper (Cu), zinc (Zn), and iron (Fe) in fifteen skin-whitening creams marketed at local shops in Islamabad, Pakistan. The concentrations of metals were analyzed by inductive coupled plasma-optical emission spectrometer (ICP-OES) after digestion with a mixture of HNO₃, HCl, and H₂O₂. The skin-whitening creams were found to have metal concentrations in parts per million (ppm) in the following range: Hg (1.0-18,210 ppm), Co (0.1992-1.9931 ppm), Cr (1.0453-2.7455 ppm), Cu (0.6987-0.1997 ppm), Fe (8.8868-28.6213 ppm), Ni (0.7487-1.5958 ppm), Pb (0.2997-4.7287 ppm), and Zn (7819.2-39,696.7 ppm). As and Cd were not detected in any of the fifteen skin-whitening creams. Only one cream (L'Oréal Paris White Perfect) was found in safe limits defined by the Food and Drug Administration for cosmetics. In order to elucidate the mechanism of lower production of melanin in presence of heavy metals, a molecular docking study was carried out by using Molecular Operating Environment (MOE) software. A good correlation was observed between experimental findings and molecular docking studies.

European Surveillance System on Contact Allergies (ESSCA): Characteristics of patients patch tested and diagnosed with irritant contact dermatitis

BACKGROUND

Irritant contact dermatitis (ICD) is caused by the acute locally toxic effect of a strong irritant, or the cumulative exposure to various weaker physical and/or chemical irritants.

OBJECTIVES

To describe the characteristics of patients with ICD in the population patch tested in the European Surveillance System on Contact Allergies (ESSCA; www.essca-dc.org) database.

METHODS

Data collected by the ESSCA in consecutively patch-tested patients from January 2009 to December 2018 were analyzed.

RESULTS

Of the 68 072 patients, 8702 were diagnosed with ICD (without concomitant allergic contact dermatitis [ACD]). Hand and face were the most reported anatomical sites, and 45.7% of the ICD was occupational ICD (OICD). The highest proportions of OICD were found in metal turners, bakers, pastry cooks, and confectionery makers. Among patients diagnosed with ICD, 45% were found sensitized with no relevance for the current disease.

CONCLUSIONS

The hands were mainly involved in OICD also in the subgroup of patients with contact dermatitis, in whom relevant contact sensitization had been ruled out, emphasizing the need for limiting irritant exposures. However, in difficult-to-treat contact dermatitis, unrecognized contact allergy, or unrecognized clinical relevance of identified allergies owing to incomplete or wrong product ingredient information must always be considered.

Associated positive patch test reactions to standard contact allergens: 10-year data from the Slovenian E-Surveillance System

BACKGROUND

A considerable share of patients tested with a baseline patch test series respond with a positive reaction to more than one allergen, and some associations between synchronous positive reactions to distinct baseline patch allergens have been described in the literature.

OBJECTIVES

To evaluate the prevalence of sensitization to haptens of the European baseline series as well as the prevalence of oligosensitization and polysensitization and the most significant associated positive patch test reactions in Slovenia.

METHODS

Patch testing data collected by the Slovenian E-Surveillance System from January 2008 to December 2017 were retrospectively analysed.

RESULTS

Of a total of 15 171 patients analysed, 39.29% showed at least one positive reaction. The highest prevalences were noted for metals (nickel[II]sulfate hexahydrate: 16.33%) and fragrances (fragrance mix I: 6.70%). The correlation analysis showed the strongest correlation between mercapto mix and 2-mercaptobenzothiazole (61.2%), fragrance Mix II and hydroxyisohexyl 3-cyclohexene carboxaldehyde (50.5%), and potassium dichromate and cobalt(II) chloride hexahydrate (33.3%).

CONCLUSIONS

Sensitization prevalences to the most common haptens were described, and their strongest correlations on a national level quantified. A comparison with other European results confirms already known associations between allergens in terms of cross-reactivity.

Wearable Woes: Allergens in Diabetic Devices

Novel diabetic devices are being developed to help manage diabetes and improve the quality of life of patients with diabetes. Both insulin pumps and glucose monitors are becoming increasingly convenient, long-lasting, and discrete for patients, but this often requires the use of strong external cutaneous adhesives and increased contact time with the skin. As a consequence, these devices have been associated with a variety of dermatologic reactions, namely, irritant and allergic contact dermatitis. Some of these reactions can be severe, precluding the use of these devices, which puts patients' long-term health at risk. Herein, we review the history of diabetic devices and reported cutaneous reactions to diabetic devices and commonly cited allergens.

A perspective on the safety of parabens as preservatives in wound care products

Antimicrobial and/or preservative ingredients incorporated in wound care products are subjected to certain safety restrictions. However, several of those agents, and paraben preservatives in particular, have been criticised. Conflicting reports on the potential of parabens to induce allergic contact dermatitis, and their assumed oestrogen‐like activity, raised public health concerns about their overall safety. Here, we seek to provide a balanced perspective on the most significant purported adverse health effects, and thereby allay the many misconceptions regarding the safety of parabens. Extensive and long‐term monitoring of paraben allergy frequencies illustrate that allergic reactions are quite uncommon, especially when compared with other antimicrobial and preservative agents. The estrogenic potential of parabens was illustrated to be far less potent than that of natural oestrogen receptor ligands, and the etiological significance of their presence in human tissue has not been established. The general consensus based on investigations by both the scientific community and regulatory agencies indicates that, with current safety regulations regarding their use in place, this effective and well‐documented group of preservatives should not warrant drastic measures to replace them. As such, despite the ongoing concern, it is indicated that, when used at typical concentrations, parabens are unlikely to affect human health.

Formaldehyde 2% is not a useful means of detecting allergy to formaldehyde releasers- results of the ESSCA network, 2015-2018

BACKGROUND

Studies suggest that patch testing with formaldehyde releasers (FRs) gives significant additional information to formaldehyde 1% aq. and should be considered for addition to the European baseline series (EBS). It is not known if this is also true for formaldehyde 2% aq.

OBJECTIVES

To determine the frequency of sensitization to formaldehyde 2% aq. and co-reactivity with FRs. To establish whether there is justification for including FRs in the EBS.

MATERIALS AND METHODS

A 4-year, multi-center retrospective analysis of patients with positive patch test reactions to formaldehyde 2% aq. and five FRs.

RESULTS

A maximum of 15 067 patients were tested to formaldehyde 2% aq. and at least one FR. The percentage of isolated reactions to FR, without co-reactivity to, formaldehyde 2% aq. for each FR were: 46.8% for quarternium-15 1% pet.; 67.4% imidazolidinyl urea 2% pet.; 64% diazolidinyl urea 2% pet.; 83.3% 1,3-dimethylol-5, 5-dimethyl hydantoin (DMDM) hydantoin 2% pet. and 96.3% 2-bromo-2-nitropropane-1,3-diol 0.5% pet. This demonstrates that co-reactivity varies between FRs and formaldehyde, from being virtually non-existent in 2-bromo-2-nitropropane-1,3-diol 0.5% pet. (Cohen's kappa: 0, 95% confidence interval [CI] -0.02 to 0.02)], to only weak concordance for quaternium-15 [Cohen's kappa: 0.22, 95%CI 0.16 to 0.28)], where Cohen's kappa value of 1 would indicate full concordance.

CONCLUSIONS

Formaldehyde 2% aq. is an inadequate screen for contact allergy to the formaldehyde releasers, which should be considered for inclusion in any series dependant on the frequency of reactions to and relevance of each individual allergen.

Patch test results with the European baseline series and additions thereof in the ESSCA network, 2015-2018

BACKGROUND

Clinical surveillance of the prevalence of contact allergy in consecutively patch tested patients is a proven instrument to continually assess the importance of contact allergens (haptens) assembled in a baseline series.

OBJECTIVES

To present current results from the European Surveillance System on Contact Allergies, including 13 countries represented by 1 to 11 departments.

METHODS

Anonymized or pseudonymized patch test and clinical data from various data capture systems used locally or nationally as transferred to the Erlangen data centre were pooled and descriptively analysed after quality control.

RESULTS

In the 4 years (2015-2018), data from 51 914 patients patch tested with the European baseline series (EBS) of contact allergens were analysed. Contact allergy to nickel was most frequent (17.6% positive), followed by contact allergy to fragrance mix I (6.9%), methylisothiazolinone (MI; 6.2%), and Myroxylon pereirae resin (balsam of Peru; 5.8%).

CONCLUSIONS

While the prevalence of MI contact allergy decreased substantially following regulatory intervention, the persistently high levels of allergy to metals, fragrances, other preservatives, and rubber chemicals point to problems needing further research and, potentially, preventive efforts. Results with national additions to the baseline series provide important information on substances possibly to be considered for inclusion in the EBS.

Non-heat inactivated autologous serum increases accuracy of in vitro CFSE lymphocyte proliferation test (LPT) for nickel

Background

Skin patch testing is still seen as the gold standard for the diagnosis of allergic hypersensitivity. For several metals and for patients with a suspected adverse reaction to their medical device implant material, patch testing can be unreliable. The current alternative to metal allergy patch testing is the in vitro lymphocyte proliferation test (LPT) using tritiated thymidine. This method is well‐established but requires handling of radioactive material, often uses heat‐inactivated allogenic human pooled serum and cannot determine T cell subsets.

Objective

To develop a radioactive free LPT by using carboxyfluorescein succinimidyl ester (CFSE) and to evaluate the influence of serum source (heat‐inactivated human pooled serum [HI HPS] vs autologous serum) on the sensitivity and specificity of the nickel‐specific LPT.

Methods

Peripheral blood mononuclear cells derived from nickel‐allergic patients and healthy controls were collected, labelled with CFSE and cultured in medium containing 10% HI HPS or 10% autologous serum with or without additional T cell skewing cytokine cocktails (Th1: IL‐7/IL‐12, Th2: IL‐7/IL‐4 or Th17: IL‐7/IL‐23/IL‐1β) in the absence or presence of NiSO₄. The stimulation index (SI) was calculated as the ratio of divided cells, that is the percentage of CFSE^low/neg CD3⁺CD4⁺ T‐lymphocytes upon nickel stimulation compared to the percentage of CFSE^low/neg CD3⁺CD4⁺ T‐lymphocytes without antigen. These results were compared with the history of Ni allergy, patch test results and the MELISA test.

Results

Autologous serum positively influenced Ni‐specific proliferation while HI HPS negatively influenced Ni‐specific proliferation. The test protocol analysing CD4⁺ cells and autologous serum without skewing cytokines scored the best diagnostic values (sensitivity 95%; specificity 93%; and overall accuracy 94%) compared to the parallel test using HI HPS (accuracy 60%). Cytokine supplements did not further improve the test protocol which used autologous serum. The protocol using HI HPS could be further improved by addition of the cytokine skewing cocktails.

Conclusions

Here, we describe an optimized and highly accurate flow cytometric LPT which comprises of CFSE‐labelled cells cultured in autologous serum (not heat inactivated) and without the presence of T cell skewing cytokines.

Clinical relevance

The sensitivity and specificity of LPT is enhanced, compared to HI HPS, when autologous serum without skewing cytokines is used.

High rate of sensitization to Kathon CG, detected by patch tests in patients with suspected allergic contact dermatitis

Background

Kathon CG, a combination of methylchloroisothiazolinone and methylisothiazolinone, is widely used as preservative in cosmetics, as well in household cleaning products, industrial products such as paints and glues. It has emerged as an important sensitizing agent in allergic contact dermatitis.

Objectives

This study evaluated the reactivity to this substance in patients subjected to patch tests at the Dermatology Institute in Bauru, São Paulo from 2015 to 2017 and its correlation with other preservatives, the professional activity and location of the lesions.

Methods

The patients were submitted to standard series of epicutaneous tests, standardized by the Brazilian Group Studies on Contact Dermatitis.

Results

Out the 267 patients tested, 192 presented positivity to at least one substance and 29 of the patients (15.10%) presented reaction to Kathon CG, with predominance of the female gender (n = 27); main professional activity associated with Kathon CG sensibilization was cleaning (17.24%), followed by aesthetic areas (13.79%) and health care (10.34%). The most prevalent sensitizations among the substances tested were nickel sulphate (56.3%), followed by cobalt chloride (23.4%), neomycin (18.2%), potassium dichromate (17.7%), thimerosal (14.5%), formaldehyde (13.2%), paraphenylenediamine (9.3%), and fragrance mix (8.3%).

Study limitations

We do not have data from patients that were submitted to patch test a decade ago in order to confront to current data and establish whether or no sensitization to Kathon CG has increased.

Conclusion

High positivity to Kathon CG corroborates the recent findings in the literature, suggesting more attention to concentration of this substance, used in cosmetics and products for domestic use.

Risk of human exposure to metals in some household hygienic products in Nigeria

•

Metal content of 27 household hygienic products available in Nigeria was determined.

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SED values for metals in these products were below tolerable intake levels.

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MoS values indicate that they are reasonably safe for human use.

•

However, products contained significant amounts of toxic and allergenic metals.

•

Effluents from use of products are likely sources of metals to the environment.

This study presents data on the levels and risk of human exposure to Cd, Pb, Cr, Ni, Cu, Co, Mn, Zn and Fe in some popular brands of household hygienic products (HHPs) available in Nigeria. The HHPs were digested with a mixture of HNO₃, HCl and HClO₄ in a ratio of 1:3:1 and the concentrations of the selected metals were quantified by atomic absorption spectrophotometry. The metal concentrations (in μg g⁻¹) in these products ranged from 0.4 to 5.4, <0.09–47.0, <0.12–43.7, <0.06–7.5, <0.12–9.5, <0.06–15.0, <0.09–24.5, 9.0–675 and 62.4–434 for Cd, Pb, Cr, Cu, Co, Ni, Mn, Zn and Fe respectively. The systemic exposure dosages for the metals, arising from the use of these HPPs, were less than their respective provisional tolerable daily intake/recommended dietary allowance values. The household hygienic products are safe to use by humans based on the margin of safety values that were all above 100. However, the products contained significant levels of toxic (Cd and Pb), allergenic (Ni and Cr) and other low toxicity metals (Mn, Zn and Fe), which could be a potential threat to the environment.

Amended Safety Assessment of Methylisothiazolinone as Used in Cosmetics

The Cosmetic Ingredient Review Expert Panel (Panel) reviewed the safety of methylisothiazolinone (MI), which functions as a preservative. The Panel reviewed relevant animal and human data provided in this safety assessment and in a previously published safety assessment of MI and concluded that MI is safe for use in rinse-off cosmetic products at concentrations up to 100 ppm and safe in leave-on cosmetic products when they are formulated to be nonsensitizing, which may be determined based on a quantitative risk assessment.

Risk Assessment of 5-Chloro-2-Methylisothiazol-3(2H)-One/2-Methylisothiazol-3(2H)-One (CMIT/MIT) Used as a Preservative in Cosmetics

The mixture of 5-chloro-2-methylisothiazol-3(2H)-one (CMIT) and 2-methylisothiazol-3(2H)-one (MIT), CMIT/MIT, is a preservative in cosmetics. CMIT/MIT is a highly effective preservative; however, it is also a commonly known skin sensitizer. Therefore, in the present study, a risk assessment for safety management of CMIT/MIT was conducted on products containing 0.0015% of CMIT/MIT, which is the maximum MIT level allowed in current products. The no observed adverse effect level (NOAEL) for CMIT/MIT was 2.8 mg/kg bw/day obtained from a two-generation reproductive toxicity test, and the skin sensitization toxicity standard value for CMIT/MIT, or the no expected sensitization induction level (NESIL), was 1.25 μg/cm²/day in humans. According to a calculation of body exposure to cosmetics use, the systemic exposure dosage (SED) was calculated as 0.00423 mg/kg bw/day when leave-on and rinse-off products were considered. Additionally, the consumer exposure level (CEL) amounted to 0.77512 μg/cm²/day for all representative cosmetics and 0.00584 μg/cm²/day for rinse-off products only. As a result, the non-cancer margin of safety (MOS) was calculated as 633, and CMIT/MIT was determined to be safe when all representative cosmetics were evaluated. In addition, the skin sensitization acceptable exposure level (AEL)/CEL was calculated as 0.00538 for all representative cosmetics and 2.14225 for rinse-off products; thus, CMIT/MIT was considered a skin sensitizer when all representative cosmetics were evaluated. Current regulations indicate that CMIT/MIT can only be used at concentrations 0.0015% or less and is prohibited from use in other cosmetics products. According to the results of this risk assessment, the CMIT/MIT regulatory values currently used in cosmetics are evaluated as appropriate.

Sensitization to Fragrance mix-1 in Patients with Contact Dermatitis in Nord-East of Italy: 1996–2016 Time Trend and Gender Effect

(1) Background: Fragrance sensitization is common in Italy and their constituents are used in many cosmetics and detergents. The objective of the study was to analyze the temporal trend of sensitivity to fragrance mix-1 in northeastern Italy and to evaluate gender differences; (2) Methods: From 1996 to 2016, 27,381 consecutive patients with suspected allergic contact dermatitis were patch tested. Individual characteristics were collected through a standardized questionnaire in six departments of dermatology or occupational medicine; (3) Results: The overall prevalence of sensitization to fragrance mix-1 was 7.3%; the prevalence was significantly higher in women (7.7%) than in men (6.3%). From 1996 to 2016, we observed an increase of this sensitization, ranging from 6.2% to 7.7% in males and from 7.2% to 9.1% in females; (4) Conclusions: Our study showed that contact allergy to fragrance mix-1 is important in both sexes and prevalence is increasing over time, despite the introduction of new fragrances with lower sensitization potential. There is the need to reduce the use of fragrances mix-1 to stop the increase of sensitization in exposed subjects.

Cutaneous Adverse Effects of Diabetes Mellitus Medications and Medical Devices: A Review

Diabetes mellitus is one of the most prevalent chronic diseases in the USA. If uncontrolled, diabetes can lead to devastating complications. Diabetes medications and medical devices largely contribute to the significant financial expense that the disease inflicts on affected individuals and society. Alongside significant economic burden, there are numerous cutaneous adverse effects associated with diabetes medications and medical devices. Despite the large and increasing number of individuals living with diabetes and the wide use of the related medications and medical devices, there is limited literature that comprehensively documents their cutaneous adverse effects. These cutaneous adverse effects are significant as they can worsen glycemic control, increase disease distress, and may increase risk of associated complications. Thus, it is important that providers can recognize these cutaneous adverse effects, identify the culprit agents, and can properly manage them. In this article, we provide a critical review of the cutaneous adverse effects of medications and devices used in the management of diabetes and provide insight into risk factors and prevention and an overview of therapeutic management. An emphasis is placed on clinical recognition and treatment for use of the medical providers who, regardless of practice setting, will treat patients with diabetes.

European Surveillance System on Contact Allergies (ESSCA): Contact allergies in relation to body sites in patients with allergic contact dermatitis

Background

Analyses of the European Surveillance System on Contact Allergies (ESSCA) database have focused primarily on the prevalence of contact allergies to the European baseline series, both overall and in subgroups of patients. However, affected body sites have hitherto not been addressed.

Objective

To determine the prevalence of contact allergies for distinct body sites in patients with allergic contact dermatitis (ACD).

Methods

Analysis of data collected by the ESSCA (www.essca‐dc.org) in consecutively patch tested patients, from 2009 to 2014, in eight European countries was performed. Cases were selected on the basis of the presence of minimally one positive patch test reaction to the baseline series, and a final diagnosis of ACD attributed to only one body site.

Results

Six thousand two hundred and fifty‐five cases were analysed. The head and hand were the most common single sites that ACD was attributed to. Differences between countries were seen for several body sites. Nickel, fragrance mix I, cobalt and methylchloroisothiazolinone/methylisothiazolinone were the most frequent allergens reported for various body sites.

Conclusions

Distinct allergen patterns per body site were observed. However, contact allergies were probably not always relevant for the dermatitis that patients presented with. The possibility of linking positive patch test reactions to relevance, along with affected body sites, should be a useful addition to patch test documentation systems.

Fragrance contact allergens in 5588 cosmetic products identified through a novel smartphone application

BACKGROUND

More than 25% of the adult European population suffers from contact allergy, with fragrance substances recognized as one of the main causes. Since 2005, 26 fragrance contact allergens have been mandatory to label in cosmetic products within the EU if present at 10 ppm or above in leave-on and 100 ppm or above in wash-off cosmetics.

OBJECTIVE

To examine exposure, based on ingredient labelling, to the 26 fragrances in a sample of 5588 fragranced cosmetic products.

METHODS

The investigated products were identified through a novel, non-profit smartphone application (app), designed to provide information to consumers about chemical substances in cosmetic products. Products registered through the app between December 2015 and October 2016 were label checked according to International Nomenclature of Cosmetic Ingredients (INCI) for the presence of the 26 fragrance substances or the wording 'fragrance/parfum/aroma'.

RESULTS

The largest product categories investigated were 'cream, lotion and oil' (n = 1192), 'shampoo and conditioner' (n = 968) and 'deodorants' (n = 632). Among cosmetic products labelled to contain at least one of the 26 fragrances, 85.5% and 73.9% contained at least two and at least three of the 26 fragrances, respectively. Linalool (49.5%) and limonene (48.5%) were labelled most often among all investigated products. Hydroxyisohexyl 3-cyclohexene carboxaldehyde (HICC/Lyral^® ) was found in 13.5% of deodorants. Six of the 26 fragrance substances were labelled on less than one per cent of all products, including the natural extracts Evernia furfuracea (tree moss) and Evernia prunastri (oak moss). A total of 329 (5.9%) products had one or more of the 26 fragrance substances labelled but did not have 'parfum/fragrance/aroma' listed on the label.

CONCLUSIONS

Consumers are widely exposed to, often multiple, well-established fragrance contact allergens through various cosmetic products intended for daily use. Several fragrance substances that are common causes of contact allergy were rarely labelled in this large sample of cosmetic products.

Screening for skin-sensitizing allergens among patients with clinically suspected allergic contact dermatitis

Objectives:

To detect common skin-sensitizing agents among patients experiencing allergic contact dermatitis (ACD).

Methods:

This was a retrospective study of 152 patients with clinically suspected ACD who underwent patch testing in an allergy clinic at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia between January 2012 and February 2015. Of these patients, only 74 (48%) patients reacted to one or more contact allergens. This group of patients included 58 (78.4%) women and 16 (21.6%) men (mean age: 37.8±13.8 years). Patch testing was performed using the thin-layer rapid-use epicutaneous patch test panels.

Results:

Nickel sulfate was the most common sensitizing agent, with 26 (35.1%) patients yielding a positive result; followed by p-phenylenediamine in 17 (22.9%), butyl-tetra-phenol formaldehyde in 12 (16.2%), gold sodium thiosulfate in 10 (13.5%), and thimerosal in 6 (8.1%) patients. Nickel reactivity was significantly higher among women (41.4%) than among men (12.5%) (p<0.0001). Similarly, gold reactivity among women (15.5%) was also higher than among men (6.2%) (p≤0.02).

Conclusion:

The high level of skin sensitization due to nickel, PPD, and gold in patients with ACD emphasizes the need for measures to decrease exposure to these sensitizing agents.

Contact allergy to fragrances: current clinical and regulatory trends

. Several fragrances are important contact allergens. Compared to the immense multitude of more than 2,500 fragrances used in cosmetics, the spectrum of single substances and natural extracts used for patch testing appears limited, albeit comprising the supposedly most important contact allergens. The present review summarizes the most important results of the opinion of the Scientific Committee on Consumer Safety on fragrance allergens in cosmetic products from July 2012. Clinical results beyond abovementioned screening allergens, animal results in terms of the LLNA and structure activity considerations point to 100 single substances and extracts, respectively, which, in addition to those 26 already identified, must be considered contact allergens, and the presence of which should be declared in cosmetics. In case of the most commonly used fragrance terpenes limonene and linalool hydroperoxides resulting from autoxidation constitute the major allergens. These have become available as patch test material recently. Altogether 12 single substances have caused a (very) high number of published cases of sensitization. Thus their use concentration should be (further) reduced or, in case of hydroxyisohexyl 3-cyclohexene carboxaldehyde (HICC, e.g., Lyral®), use should be abandoned altogether. This is also recommended in case of oak moss and tree moss due to their content of the strong sensitizers atranol and chloroatranol. As generic maximum dose for the remaining 11 single substances 0.8 µg/cm2 are suggested, which corresponds, under conservative assumptions, a maximum concentration of 100 ppm in the finished product.

Evaluation of human exposure to metals from some commonly used hair care products in Nigeria

The concentrations of nine metals, namely, cadmium (Cd), lead (Pb), chromium (Cr), copper (Cu), cobalt (Co), nickel (Ni), manganese (Mn), zinc (Zn), and iron (Fe), were determined in 26 brands of hair care products including hair relaxers, conditioners and shampoos. The study was aimed at providing information on the possible risks arising from heavy metals associated with the use of these products. The concentrations of the metals were determined by means of atomic absorption spectrophotometry after digestion of the samples with a mixture of acids. The concentrations of the respective metals in hair relaxers, shampoos and conditioners were found to be 0.8–2.5, 0.6–3.0, <LOQ-2.8 μg g⁻¹ Cd; 4.5–26.0, <LOQ-28.0, <LOQ-425 μg g⁻¹ Pb; <LOQ-0.6, <LOQ-3.4, <LOQ-4.2 μg g⁻¹ Cr; <LOQ-3.5, <LOQ-6.0, <LOQ-3.5 μg g⁻¹ Cu; <LOQ-7.0, <LOQ-7.0, 0.5–4.5 μg g⁻¹ Co; 1.0-5.5, <LOQ-10.5, 1.5–6.0 μg g⁻¹ Ni; <LOQ-9.0, 2.0–25.5, <LOQ-15 μg g⁻¹ Mn; 36.5–48.0, 35.5–1080 μg g⁻¹, 30.0–69.0 μg g⁻¹ Zn; and 84.5–123, 66.7–284, 57.6–153 μg g⁻¹ Fe respectively. The systemic exposure dosage (SED) values of the studied metals were below their respective provisional tolerable daily intakes (PTDI)/recommended daily intakes (RDI), while the margins of safety were greater than 100 which indicate that these products are safe to use.