Need for new strategies to improve the recall and avoidance rates of contact allergens: A retrospective cohort study from Turkey

BACKGROUND

Previous studies reported a low-to-moderate benefit from patch testing regarding allergen recall and avoidance.

OBJECTIVES

To determine the allergen recall and avoidance rates of patients with allergic contact dermatitis (ACD) in Turkey.

METHODS

This was a retrospective cohort study based on a phone questionnaire of 465 patients diagnosed with ACD from major allergen groups, that is, metals, preservatives, rubber, fragrances (ubiquitous allergens) and hair dye/black henna, topical drug and resins (nonubiquitous allergens), at our tertiary referral centre between 1996 and 2018.

RESULTS

Among 176 responders, allergen groups were remembered better (53.4%) than the individual allergens (36.9%). Age <40 years and keeping the allergy pass had a significantly positive impact on the recall rate of methylchloroisothiazolinone/methylisothiazolinone and nickel, particularly non-occupational nickel allergy from metal jewellery in females, respectively. Exacerbations of ACD (56.3%) were mainly due to reexposures to ubiquitous allergens. 42.9% of patients with occupational ACD changed or quit their job, most of them being construction workers and hairdressers, showing a high share (83.3%) of benefit.

CONCLUSIONS

The overall rates of allergen recall and avoidance were moderate. New strategies are needed to improve the recall and avoidance rates of contact allergens, such as increased use of allergy pass, smartphone applications and legal precautions.

Analysis of Hexavalent Chromium in Cement Samples From Countries Within and Outside the EU: A Study From the International Contact Dermatitis Research Group

Background: Allergic contact dermatitis (ACD) caused by hexavalent chromium (Cr(VI)) is often severe and difficult to treat. The content of Cr(VI) in cement can be reduced by, for example, addition of iron(II) sulfate. Since 2005 the content of Cr(VI) in cement is regulated in the EU Directive 2003/53/EC and must not exceed 2 ppm. Since this regulation came into force, ACD caused by cement has markedly been reduced. Objective: To investigate Cr(VI) and total chromium content in samples of cement from countries within and outside the EU. Methods: The members of the International Contact Dermatitis Research Group (ICDRG) were invited to participate in the study with the aim to collect cement samples from geographically different areas. The content of Cr(VI) in the samples was estimated by the diphenyl carbazide spot test, atomic absorption spectroscopy was used to assess the total chromium content. Results: Forty-five cement samples were analyzed, containing amounts of Cr(VI) from <0.1 to >70 ppm. Twenty-one samples contained >2 ppm Cr(VI), 24 contained less. Four of 17 samples from within the EU contained >2 ppm Cr(VI), that is, higher amounts than stipulated in the EU directive, as compared with 17 samples from countries outside the EU. Conclusion: In countries outside the EU, significantly more cement samples contained >2 ppm Cr(VI).

Tobramycin and antiglaucoma agents as increasing culprits of periorbital allergic contact dermatitis from topical ophthalmic medications: A 24-year study from Turkey

BACKGROUND

Allergic contact dermatitis (ACD) from topical ophthalmic medications (TOMs) poses an additional disease burden to patients who already suffer from eye problems.

OBJECTIVES

To investigate the epidemiological/clinical profile of patients with periorbital ACD from TOMs in Turkey.

PATIENTS AND METHODS

This was a retrospective, cross-sectional, single tertiary centre study based on files of 75 patch tested patients with suspected periorbital ACD from TOMs among a total of 2801 consecutively patch tested patients with suspected ACD of any origin between 1996 and 2019.

RESULTS

Periorbital ACD was diagnosed in 25 of 75 (33.3%) patients (female:male = 1.8:1; age range: 6-85 years) with suspected ACD from TOMs showing an overall prevalence of 0.9% (25/2801) among the whole patch test population. Atopy was not present. Tobramycin-containing TOMs were the most frequent culprits, followed by antiglaucoma preparations. Their frequency increased, whereas no new cases of neomycin-induced ACD were observed after 2011. Positivities with thimerosal were of unknown clinical relevance, while benzalkonium chloride (BAC) caused ACD in two patients. The diagnosis would be missed in each 20% of patients without performing day (D) 4 and D7 readings and strip-patch testing. Ten culprits were identified only by testing with patients' own TOMs in eight (32%) patients.

CONCLUSIONS

Aminoglycosides, particularly tobramycin, were the leading cause of ACD from TOMs. The frequency of ACD from tobramycin and antiglaucoma medications increased after 2011. BAC was a rare but important allergen. Additional D4 and D7 readings, strip-patch testing, and testing with patients' own TOMs seem essential when patch testing with eye medications.

Long-term dupilumab therapy in Netherton syndrome with severe atopic manifestations: Case report and review of the literature

We herein present a unique patient of Netherton syndrome (NS) with ichthyosis linearis circumflexa (ILC) lesions associated with severe atopic manifestations since infancy, showing different responses of atopic and ILC lesions to a 2-year dupilumab therapy. The atopic eczematous lesions and pruritus healed remarkably, dramatically improving the patient's quality of life, whilst the scalp hair showed a clinical and light microscopic improvement. The additional recovery in axillary/pubic/extremity hair growth, sweating and nail growth in the presented case was not previously reported in NS patients treated with dupilumab. However, dupilumab had no therapeutic effect on ILC lesions which were not pruritic and showed a treatment-independent wax and waned course.

Occupational allergic contact dermatitis: A 24-year, retrospective cohort study from Turkey

BACKGROUND

Limited data exist on occupational allergic contact dermatitis (OACD) in Turkey.

OBJECTIVES

To investigate the epidemiologic profile of OACD in Turkey.

METHODS

A retrospective cohort study on 294 patients with OACD among 2801 consecutively patch-tested patients in the Allergy Unit of the Dermatology Department of İstanbul Faculty of Medicine between 1996 and 2019.

RESULTS

The overall prevalence of OACD was 10.5%, showing a male predominance. OACD was most frequently seen in construction workers (45.2%), followed by hairdressers, metalworkers, health care workers, and miscellaneous. The main relevant allergens were chromium in cement, thiurams in rubber gloves, hairdressing chemicals, resins/glues/plastics, metals, isothiazolinones, and fragrances. Hands were the mainly involved site (95.6%). Airborne eczema was observed in 21.4%. Hand and foot eczema and co-sensitizations to chrome and thiuram and chrome and cobalt were significantly associated with being a construction worker. Sensitizations to isothiazolinones in house painters, ammonium persulfate and p-phenylenediamine in hairdressers, and colophonium increased after 2010.

CONCLUSION

This was the largest group of data on OACD from Turkey, reflecting the importance of rubber glove allergy in all occupations and the striking increase in ammonium persulfate allergy among hairdressers. Chrome and cobalt were still the main cement allergens in Turkey, where the cement directive is not yet in force.

How does working in pandemic units affect the risk of occupational hand eczema in healthcare workers during the coronavirus disease-2019 (COVID-19) pandemic: A comparative analysis with nonpandemic units

BACKGROUND

Hand eczema (HE) has increased among healthcare workers (HCWs) working in coronavirus disease-2019 (COVID-19) units, and was associated with increased hand hygiene practices.

OBJECTIVES

To compare the prevalence and clinical characteristics of HE, and hand hygiene practices in HCWs working in COVID-19 and non-COVID-19 units.

METHODS

A total of 244 HCWs working in COVID-19 (n = 118) and non-COVID-19 patient care units (n = 126) were examined by dermatologists with regard to demographic parameters and hand hygiene practices. The COVID-19 and non-COVID-19 groups were matched at a 1:1 ratio according to age, atopy, and generalized dry skin.

RESULTS

HE was more frequent in the COVID-19 group (48.3% vs 12.7%, P < .001), whereas working years (P < .05) and additional housework at home (P < .001) were longer in the non-COVID-19 group. After the development of HE, moisturizing creams were reported to be more frequently used in the COVID group (P < .001). Topical corticosteroids were used in a minority (40% in the COVID group and 26.7% in the non-COVID group).

CONCLUSIONS

HCWs in COVID-19 units developed HE more frequently. A majority increased the frequency of moisturizer use, instead of using topical corticosteroids, after the development of HE for the purpose of treating eczema. New approaches are needed for the prevention and management of HE in HCWs, especially by facilitating access to dermatologists.

Patch-test results in terms of the recently recommended allergens in children and adolescents: A retrospective cohort study over 22 years from Turkey

BACKGROUND

A European pediatric patch-test series was suggested recently.

OBJECTIVES

To evaluate the patch-test results in children (<10-years-old) and adolescents (10- to 18-years-old) in Turkey, focusing on the clinical/occupational relevance and the diagnostic value of the recently suggested series.

PATIENTS AND METHODS

A retrospective cohort study on 317 consecutively patch-tested patients ≤18 years of age, between 1996 and 2017.

RESULTS

The contact sensitization rate was 46.1%. Allergic contact dermatitis (ACD) was diagnosed in 30.9%, comprising non-occupational (84.7%) and occupational (15.3%) ACD. Nickel was the leading allergen in almost every age group. Methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) was the clinically most relevant allergen, followed by p-phenylenediamine (PPD), ammonium persulfate, fragrance mix I, nickel sulfate, and mercury/mercury(II)amidochloride. Occupational ACD was most frequently seen in hairdresser apprentices (adolescents only) who were sensitized with PPD ± ammonium persulfate. ACD from MCI/MI increased to 5-fold, ammonium persulfate and mercurial compounds to 2-fold, and PPD to 1.7-fold after 2007. Almost one third of patients would be missed by testing only with the recommended allergens.

CONCLUSIONS

For patch testing in Turkish children and adolescents, we suggest additionally testing with ammonium persulfate, mercury/mercury(II)amidochloride, toluenesulfonamide formaldehyde resin, and polyethylene glycol, the latter as a marker for nitrofurazone allergy, in appropriate patients.

The impact of COVID-19 pandemic on the management of patients with chronic urticaria: An observational two-center study from Turkey

The Coronavirus Disease 2019 (COVID‐19) outbreak significantly affected the clinical practice in hospitals and the management of many diseases. The aim of this study was to evaluate the effect of pandemic‐related factors on the severity and course of chronic urticaria (CU). A total of 194 CU patients who were on regular follow‐up, were enrolled in the study. The disease activity was assessed by means of the weekly urticaria activity score (UAS7) and urticaria control test (UCT). Patients were divided into two subgroups according to their disease aggravation as “aggravated” and “non‐aggravated”. Two groups were compared in terms of demographic, clinical, COVID‐19‐associated parameters, and parameters related with the effect of COVID‐19 pandemic on CU management. The omalizumab use was statistically higher (P = .017), and the systemic corticosteroid use was statistically lower (P = .025) in the “aggravated” group. Adherence to quarantine was significantly lower in the “aggravated” group (P = .027). 173 patients (89.2%) were unable to contact a dermatologist during the pandemic. Among 186 patients who received treatment for CU before the pandemic, 48 (25.8%) did not continue the existing treatment during the pandemic. CU aggravated in one patient with COVID‐19 and remained stable in the other. This study showed that CU patients, especially those on omalizumab therapy, had difficulties in attending medical care and even in the maintenance of their existing therapies during the pandemic. Creating novel follow‐up and treatment models as well as the increased use of teledermatology might be beneficial in the management of this life‐disturbing condition.

Methylchloroisothiazolinone/methylisothiazolinone and methylisothiazolinone contact allergy: A 24-year, single-center, retrospective cohort study from Turkey

BACKGROUND

Methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) and MI allergy caused a global epidemic during the period 2010 to 2015, reaching its peak in 2013/14.

OBJECTIVE

To investigate the characteristics of MCI/MI and MI allergy in Turkey over 24 years.

METHODS

A total of 2310 patients patch tested between 1996 and 2019 with MCI/MI 0.01% aq. or MCI/MI 0.02% aq., with or without MI 0.2% aq., were analyzed.

RESULTS

The overall prevalence of contact sensitization was 3.3% (n = 77) with a peak level of 16.4% in 2015. The prevalence gradually decreased thereafter, but was still high (6.5%) in 2019. Seventy-three patients had clinically relevant sensitizations. MI could detect clinically relevant sensitizations in all seven patients with a negative patch test reaction to MCI/MI 0.02%. Non-occupational allergic contact dermatitis (ACD) was most frequently seen, mainly in women, with hand/face eczema from rinse-off or leave-on cosmetics, such as wet wipes. Occupational ACD was mainly seen among men with airborne eczema from wall paints in house painters, or with hand eczema from hair gel/wax in men's barbers.

CONCLUSIONS

The prevalence of MCI/MI and MI sensitization in Turkey following the peak in 2015 is still high. This is probably due to the currently allowed level of 100 ppm for MI in rinse-off cosmetics. This needs to be urgently reduced.

Foot contact dermatitis: nitrofurazone as the main cause in a retrospective, cross-sectional study over a 16-year period from Turkey

BACKGROUND

The major causative agents in allergic contact dermatitis of the foot may differ from country to country. Sufficient data on foot eczema in patients from Turkey are lacking.

OBJECTIVE

To identify the clinically relevant contact allergens in foot eczema and determine the role of patch test series and patients' own materials in the detection of the responsible allergens.

METHODS

Among 1753 patients patch tested between 1996 and 2012 in our clinic, 53 with suspected allergic foot eczema were enrolled in this retrospective, cross-sectional study. Forty nine patients were patch tested with the extended European baseline series, 49 with supplemental series including rubber, leather, topical drugs, textile, cosmetic series containing preservatives and emulgators and varnish/plastic/glue series, and 37 with their own substances.

RESULTS

Thirty of the 53 patch tested patients showing sensitization to at least one clinically relevant allergen were diagnosed with allergic foot eczema. The main eliciting agent was nitrofurazone (n = 8), followed by leather shoe allergens, ie, potassium dichromate (n = 6), p-tert-butylphenol formaldehyde resin and formaldehyde, in the second range. Rubber shoe allergens were less frequently observed (n = 3). In more than 1/3 of the patients, the causative agent could only be identified by testing the patient's own substances and/or supplemental series.

CONCLUSION

Nitrofurazone was the leading causative agent followed by leather shoe allergens. Pediatric patients were frequently sensitized with shoe allergens. Patch testing with patient's own substances had a critical value in the detection of the causative agent in a significant number of patients.

Investigation of enterovirus infections, autoimmune factors and HLA genotypes in patients with T1DM

AIM

Besides of genetic and autoimmun factors, role of viral infections have been investigated in pathogenesis of type 1 diabetes mellitus (T1DM). The aim of this study was to determine enterovirus (EV) infections, glutamic acid decarboxylase (GAD) antibody positivity and HLA genotype distribution in T1DM patients with respect to corresponding healthy subjects. This is the first study in Turkey designed to investigate enteroviral infections and autoimmune and genetic factors together in this group of patients.

METHODS

EV RNA, coxsackie virus B type 4 (CV-B4) antibodies, GAD antibodies and HLA genotypes were investigated in 86 patients with T1DM and in 100 control subjects.

RESULTS

EV RNA was not detected in either the patient or control group. CV-B4 type antibodies and GAD antibodies were identified in 66.3% and 47.6% patients and 55.0% and 19% control subjects, respectively (for GAD antibodies P=0.001). High-risk HLA-DQ and high-risk HLA-DR genotypes for T1DM were identified in 67.3% and 86.0% of patients, respectively, and the difference was significantly higher compared with controls (34% and 40%, respectively, P=0.001).

CONCLUSION

There was no significant relation between CV-B4 neutralizing antibody, GAD antibody positivity and high-risk HLA genotypes in patients. In conclusion, no correlation was found in this study between T1DM and EV infections. In addition, there was no relation between EV infections and T1DM in patients with high-risk genotypes or in patients with autoimmunity.

Netherton syndrome associated with growth hormone deficiency

Netherton syndrome (NS) is a rare autosomal recessive disorder characterized by ichthyosiform scaling, hair abnormalities, and variable atopic features. Mutations in the serine protease inhibitor Kazal type 5 (SPINK5) gene leading to lymphoepithelial Kazal-type-related inhibitor (LEKTI) deficiency cause NS. Growth retardation is a classic feature of NS, but growth hormone (GH) deficiency with subsequent response to GH therapy is not documented in the literature. It is proposed that a lack of inhibition of proteases due to a deficiency of LEKTI in the pituitary gland leads to the overprocessing of human GH in NS. Herein we report three patients with NS who had growth retardation associated with GH deficiency and responded well to GH therapy.

Eczematous-type multiple drug allergy from isoniazid and ethambutol with positive patch test results

Multiple drug allergy (MDA) is characterized by hypersensitivity to 2 or more chemically unrelated drugs. Multiple drug allergy from simultaneous use of antituberculosis drugs is a rare phenomenon that mainly presents as an urticarial or maculopapular eruption. This case report describes a 58-year-old man who developed a generalized eczematous eruption during the sixth week of oral therapy with 4 antituberculosis drugs-isoniazid, ethambutol, rifampicin, and morphazinamide-for treatment of suspected pleural tuberculosis. The eruption resolved after treatment with systemic corticosteroids and cessation of isoniazid and ethambutol. During a lesion-free period 6 months after cessation of the corticosteroids, patch testing with serial dilutions of isoniazid and ethambutol revealed positive reactions; irritant patch test reactions were excluded by testing with graded concentrations of each drug. The patient avoided the causative drugs and reported no new eruptions at 1-year follow-up. It is important for dermatologists to consider the value of patch testing in determining the causative drugs in suspected cases of eczematous-type MDA.