Continuous usage of a hair dye product containing 2-methoxymethyl-para-phenylenediamine by hair-dye-allergic individuals

BACKGROUND

Despite a positive patch test reaction to para-phenylenediamine (PPD) and/or toluene-2,5-diamine (PTD), many people attempt to continue dyeing their hair with products containing PPD or its derivatives.

OBJECTIVES

Investigation of elicitation reactions among PPD/PTD-allergic individuals to hair dye products containing the less sensitizing PPD derivative 2-methoxymethyl (ME)-PPD.

METHODS

Elicitation reactions were studied in 43 PPD/PTD-allergic individuals by a 45-min pretest with an ME-PPD-containing hair dye on their forearm. Upon a negative result this was followed by exposure to subsequent hair colour treatment(s).

RESULTS

Overall, 38 of 43 PPD/PTD-allergic individuals did not develop an elicitation reaction during the pretest with ME-PPD-containing hair dye products, and were eligible for subsequent hair colour treatments. Of these 38 PPD/PTD-allergic individuals, 29 tolerated subsequent hair dyeing with ME-PPD-containing hair dye products, while seven showed mild and two showed moderate/marked allergic reactions upon the first hair colour treatment.

CONCLUSIONS

Hair dye products with the less sensitizing ME-PPD were tolerated by 29 of 43 (67%) PPD/PTD-allergic individuals throughout continued hair dyeing with an average of nine treatments per year. Five individuals reacted upon pretesting, while only mild-to-moderate/marked skin reactions occurred upon hair dyeing in nine individuals who were not identified by the pretest. To our knowledge this is the first study among PPD/PTD-allergic individuals indicating that a negative 45-min pretest with a hair dye product helps to avoid severe allergic reactions.

Prevalence of fragrance contact allergy in the general population of five European countries: a cross-sectional study

BACKGROUND

Contact allergy to fragrances is assessed mostly in clinical populations of patients. Studies in the general population are scarce and vary in their methodology across countries.

OBJECTIVES

To determine the prevalence of fragrance contact allergy in the European general population and to assess the clinical relevance of positive patch test reactions to different fragrances.

METHODS

In five European countries (Germany, Italy, the Netherlands, Portugal and Sweden) a random sample from the general population aged 18-74 years was drawn. In total, 12 377 subjects were interviewed in this cross-sectional study and a random sample (n = 3119) was patch tested using the TRUE Test and Finn Chamber techniques. Patch test procedures were harmonized by mandatory training before the study and monitoring during the study.

RESULTS

The highest prevalence for contact allergy of 2·6% [95% confidence interval (CI) 2·1-3·2] was found for fragrance mix (FM) I in petrolatum, with a high content of atranol and chloratranol, followed by 1·9% (95% CI 1·5-2·4) for FM II in petrolatum. The conservatively estimated prevalence of fragrance contact allergy was 1·9% (95% CI 1·5-2·5). This is defined as the existence of a positive patch test to FM I or FM II; any of their individual materials; Myroxylon pereirae; sesquiterpene lactones or 3- and 4-hydroxyisohexyl 3-cyclohexene carboxaldehyde that show clinical relevance, defined conservatively as lifetime avoidance of scented products and an itchy skin rash lasting > 3 days in a lifetime. Using the reported lifetime prevalence of any contact dermatitis instead of the lifetime prevalence of any itchy skin rash, the prevalence is 0·8% (95% CI 0·5-1·2). The prevalence rates of contact allergy to fragrances in women are about twice those in men.

CONCLUSIONS

This study helps to identify targets for prevention of fragrance allergy.

Cross-elicitation responses to 2-methoxymethyl-p-phenylenediamine under hair dye use conditions in p-phenylenediamine-allergic individuals

BACKGROUND

The factors influencing elicitation responses in individuals allergic to p-phenylenediamine (PPD) in hair dyes are not well understood.

OBJECTIVES

Investigation of the elicitation response to the new, less-sensitizing PPD alternative 2-methoxymethyl-p-phenylenediamine (ME-PPD) under simulated hair dye use conditions.

METHODS

The cross-elicitation response to ME-PPD (2% in a hair dye test product for 30 min on forearm then rinsing) was analysed at days 2 and 3 in 30 PPD-allergic individuals with diagnostic patch test grades +, ++ or +++ according to the classification of the International Contact Dermatitis Research Group.

RESULTS

Cross-reactivity to the ME-PPD-containing hair dye test product was elicited in nine of 30 subjects (30%), while 70% were negative. Cross-reactivity was elicited in two of four cases with grade +++, three of 10 with grade ++ and four of 16 with grade +. Under identical conditions, PPD was previously found to elicit a response in 21 of 27 PPD-allergic individuals. In 18 of these 21 individuals, either the strength of the cross-elicitation response to ME-PPD was decreased or no response occurred.

CONCLUSIONS

Under simulated hair dye use conditions, a significantly lower degree of cross-elicitation to ME-PPD (30%) was observed than previously reported for PPD (32 of 38, 84%). Additionally, a decreased cross-elicitation strength was observed across all three patch test grades, likely reflecting the reduced skin-sensitization properties of ME-PPD. Consequently, careful dermatological evaluation is required to assess cross-reactivity to ME-PPD in patients allergic to hair dyes.

Elicitation of the immune response to p-phenylenediamine in allergic patients: the role of dose and exposure time

BACKGROUND

Usage of hair dye products containing p-phenylenediamine (PPD) is a concern for PPD-allergic individuals.

OBJECTIVES

The present study investigates the role of dose and exposure time on elicitation of allergic contact dermatitis under conditions of permanent hair dyeing.

METHODS

Elicitation responses after application of a typical hair dye product containing 2% PPD for 30 min followed by rinsing were analysed in 38 PPD-allergic individuals with a documented history of hair dye-related allergy. Skin binding experiments in vitro were performed to distinguish the dose available for elicitation from the dose applied.

RESULTS

A positive reaction was elicited in 20 of 20 patients with grades ++ to +++ and 12 of 18 with grade + according to the classification of the International Contact Dermatitis Research Group. Under conditions of diagnostic patch testing (48 h exposure), the dose available for elicitation is more than 10-fold higher compared with the dose available for hair dyeing (30-min exposure, rinsing of product).

CONCLUSIONS

This investigation demonstrates that under simulated hair dye use conditions the actual exposure to PPD is more than an order of magnitude lower than under diagnostic patch testing, although sufficient to elicit a clearly noticeable reaction in 84% of PPD patch test-positive individuals.

Para-phenylenediamine and allergic sensitization: risk modification by N-acetyltransferase 1 and 2 genotypes

BACKGROUND

Para-phenylenediamine (PPD) is a common contact sensitizer causing allergic contact dermatitis, a major skin problem. As PPD may need activation to become immunogenic, the balance between activation and/or detoxification processes may influence an individual's susceptibility. PPD is acetylated and the metabolites do not activate dendritic-like cells and T cells of PPD-sensitized individuals.

OBJECTIVES

To investigate whether PPD can be acetylated in vitro by the two N-acetyltransferases 1 (NAT1) and 2 (NAT2). Based on the assumption that N-acetylation by NAT1 or NAT2 is a detoxification reaction with respect to sensitization, we examined whether NAT1 and NAT2 genotypes are different between PPD-sensitized individuals and matched controls.

METHODS

Genotyping for NAT1 and NAT2 polymorphisms was performed in 147 PPD-sensitized individuals and 200 age- and gender-matched controls. Results Both PPD and monoacetyl-PPD were N-acetylated in vitro by recombinant human NAT1 and to a lesser extent by NAT2. Genotyping for NAT1*3, NAT1*4, NAT1*10, NAT1*11 and NAT1*14 showed that genotypes containing the rapid acetylator NAT1*10 allele were under-represented in PPD-sensitized cases (adjusted odds ratio 0.72, 95% confidence interval 0.45-1.16). For NAT2, NAT2*4, NAT2*5AB, NAT2*5C, NAT2*6A and NAT2*7B alleles were genotyped. Individuals homozygous for the rapid acetylator allele NAT2*4 were under-represented in cases compared with controls (4.3% vs. 9.4%), but this trend was not significant.

CONCLUSIONS

With respect to data indicating that NAT1 but not NAT2 is present in human skin, we conclude that NAT1 genotypes containing the rapid acetylator NAT1*10 allele are potentially associated with reduced susceptibility to PPD sensitization.

Association between TNFA-308 G/A polymorphism and sensitization to para-phenylenediamine: a case-control study

BACKGROUND

Para-phenylenediamine (PPD) and related chemicals are common contact sensitizers, frequently causing allergic contact dermatitis (ACD). The cytokine tumor necrosis factor-alpha (TNF-alpha) plays a key role in contact sensitization.

METHODS

In this case-control study, we evaluated the distribution of variations in the regulatory region of the gene for TNF-alpha (TNFA-308 G/A) in 181 Caucasian individuals with a history of ACD and sensitization to PPD and 161 individuals with no history of sensitization to PPD.

RESULTS

The frequency of GA or AA TNFA genotypes was significantly higher in individuals sensitized to PPD than in age- and gender-matched controls giving an odds ratio (OR) of 2.16 (95% confidence interval, CI: 1.35-3.47; P = 0.0016). This relation was even more pronounced when restricting cases to females over 45 years (OR = 3.71; 95% CI: 1.65-8.31; P = 0.0017) vs younger females (less than or equal to 45 years; OR = 2.41; 95% CI: 1.03-5.65; P = 0.044) or males (OR = 1.05; 95% CI: 0.449-2.47; P = 1.0). In addition, a logistic regression model revealed a significant effect for TNFA-308 AA and AG vs GG genotype (point estimate = 2.152; 95% Wald CI: 1.332-3.477).

CONCLUSIONS

These findings suggest a possible role for the TNFA-308 genetic polymorphism as a susceptibility factor for chemically induced ACD.

Assessment of severity of hand eczema: discrepancies between patient- and physician-rated scores

BACKGROUND

In clinical practice or trials on hand eczema the severity of this disease can be 'measured' in different ways: by means of a physician-rated clinical severity score, a patient-rated clinical severity score or by an indicator of the burden of disease. We assume that the patient-rated severity score corresponds more with the (change in) burden of disease than with the physician-rated severity score.

OBJECTIVES

To demonstrate how physicians and patients differ in their assessment of the severity of hand eczema as seen in a physician-rated severity score, patient-rated severity score and a burden of disease questionnaire.

METHODS

We used data from an open-label randomized controlled trial which was set up in two university hospital dermatology departments in the Netherlands, specializing in hand eczema. One hundred and fifty-eight patients with moderate to severe chronic hand eczema were included. The main outcome measures were the physician-rated severity score, based on five visible aspects of hand eczema (desquamation, erythema, vesicles, infiltration, fissures), the patient-rated severity score (a self-rating scale), a burden of disease questionnaire (the Dermatology Life Quality Index, DLQI) and the correlations between these parameters, both at inclusion and over time.

RESULTS

Only desquamation and infiltration were significantly correlated with patient-rated severity score. Patient-rated severity score correlated with seven of 10 DLQI items, but it did not correlate with the items regarding influence on clothes worn, impairment of sporting activities, and problems associated with treatment of the skin. The majority of patients showed improvement in all parameters after treatment. However, the improvement in patient-rated severity score was not clearly correlated with changes in physician-rated severity score. Except for DLQI item 1 (itch, soreness, pain, stinging), none of the changes in burden of disease was correlated with changes in patient-rated severity score. For each DLQI item, change over time correlated weakly with decreases in several, but not all, components of the physician-rated severity score.

CONCLUSIONS

Disease severity can be expressed by different scores; these scores are not clearly correlated, and measure different aspects. Patient satisfaction is not guaranteed when treatment is focused solely on the visible aspects of hand eczema. Instead, burden of disease has a greater impact.

Contact allergy and respiratory/mucosal complaints from heroin (diacetylmorphine)

After the start of heroin (diacetylmorphine)-assisted treatment to a selected group of chronic treatment-resistant heroin-dependent patients in the Netherlands, we reported about work-related eczema and positive patch tests to heroin in some nurses and nasal and respiratory complaints. To investigate the prevalence of heroin contact allergy, we started a questionnaire-based study with follow-up by allergological examinations. Of 120 questionnaires sent, 101 (84%) was returned: 67 from nurses and 34 from other employees. Of 101 workers, 38 (38%) had reported work-related complaints: 33 of 67 (49%) nurses and 5 of 34 (15%) other employees. Patch tests to heroin were performed in 24 nurses and were positive in 8 (33%). All the 8 had eyelid or facial eczema and, in 6, accompanied by mucosal or respiratory complaints. The prevalence of heroin contact allergy in this study was 8% (8/101) among all employees and 12% (8/67) among nurses. Respiratory and mucosal complaints could not be ascribed to a contact allergy, and in these cases, serum was analysed for specific immunoglobulin E to heroin. A type 1 allergy to heroin could not be shown. These complaints are possibly due to the histamine-liberating effect of heroin, to atopic constitution, to a combination of these factors or - less likely - to other non-allergic factors.

The European standard series in 9 European countries, 2002/2003 - First results of the European Surveillance System on Contact Allergies

Since January 2001, the European Surveillance System on Contact Allergies (ESSCA), supported by European Union funding (contract QLK4-CT-2001-00343), has started to collect patch-test data. This comprises a standardized clinical history and the patch-test results using the European standard series, from 17 centres in 9 European countries listed above. In 2002 and 2003, 10 511 patients' test results have been pooled and analysed. The anamnestic data partly reflect the subspecialties of some centres. The most common allergen was nickel sulfate (17.3%); however, large international variations were observed. The prevalence of contact allergy to Myroxylon pereirae resin (balsam of Peru) (5.8%) is coming close to the frequency found with the fragrance mix (6.4%). Regarding contact allergy to chromium compounds, different frequencies were noted in the 2 centres focused on occupational dermatitis (2.3% in the FIOH versus 7.4% in the Nofer Institute). These most likely reflect the beneficial effect of addition of ferrous sulfate in one, but not the other country. As differences may partly be due to different patch-test reading, standardization may need to be refined further. By providing post-marketing surveillance in the field of contact allergy, ESSCA will meet its objective of increased consumer safety across Europe.

The European standard series in 9 European countries, 2002/2003 -- first results of the European Surveillance System on Contact Allergies

Since January 2001, the European Surveillance System on Contact Allergies (ESSCA), supported by European Union funding (contract QLK4-CT-2001-00343), has started to collect patch-test data. This comprises a standardized clinical history and the patch-test results using the European standard series, from 17 centres in 9 European countries listed above. In 2002 and 2003, 10 511 patients' test results have been pooled and analysed. The anamnestic data partly reflect the subspecialties of some centres. The most common allergen was nickel sulfate (17.3%); however, large international variations were observed. The prevalence of contact allergy to Myroxylon pereirae resin (balsam of Peru) (5.8%) is coming close to the frequency found with the fragrance mix (6.4%). Regarding contact allergy to chromium compounds, different frequencies were noted in the 2 centres focused on occupational dermatitis (2.3% in the FIOH versus 7.4% in the Nofer Institute). These most likely reflect the beneficial effect of addition of ferrous sulfate in one, but not the other country. As differences may partly be due to different patch-test reading, standardization may need to be refined further. By providing post-marketing surveillance in the field of contact allergy, ESSCA will meet its objective of increased consumer safety across Europe.

Skin disease in paper mill workers

BACKGROUND

Paper mill workers have frequent and prolonged exposure to skin irritants and allergens and may have a higher risk of developing occupational dermatitis. Aims The aim of this study was to determine the extent of skin problems in a paper mill and how much was attributable to contact with allergens.

METHODS

A cross-sectional study was carried out among 80 paper mill workers having daily exposure to skin irritants and allergens. They all completed a questionnaire, underwent a standard interview and physical examination. Workers whose history indicated possible contact allergy were patch tested and prick tested.

RESULTS

Workers reported a high exposure to skin irritants, especially when carrying out tasks that caused the hands and feet to become wet from perspiration and having contact with process water. Atopic dermatitis was seen in 3% of the workers. Contact dermatitis was seen in 26% of the workers and 36% were diagnosed with mycosis of the feet. All cases of contact dermatitis and mycosis could be attributed to occupational exposure to skin irritants. No cases of relevant contact allergy were seen.

CONCLUSION

Occupational dermatitis in paper mills is primarily related to the exposure to skin irritants. Occupational physicians should be aware of the risk of occupational dermatitis in paper mill workers.

[Therapy of hand eczema. What can we learn from the published clinical studies?]

Hand eczema is a very common skin disease, which can be induced by different causes. Although many interventions ranging from topical corticosteroids and UV therapy to oral cyclosporine and retinoids are available, the treatment of hand eczema can be very difficult and frustrating. The objective of our study was to assess the external evidence of different treatment modalities for hand eczema. Electronic databases (Cochrane, MEDLINE, Embase, Pascal, Jicst-Eplus, Amed) were systematically searched for clinical trials on therapy for hand eczema. Additionally, four general medical journals (BMJ, JAMA, Lancet, NEJM) and 17 specialists dermatological journals were hand searched from 1977 to August 2004. A total of 100 studies were found and 31 identified as randomised clinical trials (RCTs) dealing with different interventions. Due to the poor quality of most of these RCTs, they are inadequate as a guide to clinical practice. There is a need for high-quality RCTs on therapy for hand eczema regarding established as well as new treatment options taking different subgroups of hand eczema into consideration.

Characteristics of wet work in nurses

BACKGROUND OBJECTIVES

Nursing is known for its high prevalence of hand dermatitis, mainly caused by the intense exposure to wet work in nursing activities. We aimed to study the characteristics of wet work exposure in nursing.

METHOD

Trained observers monitored the duration and frequency of different wet work activities in 45 randomly chosen nurses from different wards during a morning shift, using a method of continuous observation based on labour-observation techniques.

RESULTS

Wet work in intensive care units accounted for 24% of the overall morning shift duration, with a frequency of 49 incidents. This was 16% in dialysis wards, with a frequency of 30 incidents, and 9% on regular wards, with a frequency of 39 incidents. The wet work activities had short mean duration cycles. The mean duration of occlusion by gloves was 3.1 min on regular wards and 6.7 min in intensive care units.

DISCUSSION

The characteristics of wet work in nurses differed substantially, depending on the ward. According to the German regulation TRGS 531, our observations classify nursing as a wet work occupation, due to the frequency of wet work rather than its duration. The mean duration of occlusion in our observations was short, which makes an occlusion-induced irritating effect doubtful. Reduction in wet work exposure in nursing on regular wards could focus on the reduction of the frequency of hand-washing and patient-washing. We suggest increasing the use of gloves for patient washing. Although this will increase exposure to occlusion from gloves, it may reduce the frequency of exposure to water and soap by about a quarter.

Characteristics of wet work in the cleaning industry

Wet work is the main cause of occupational contact dermatitis in the cleaning industry. Dermatologists and occupational physicians need to base their primary and secondary prevention for workers in the cleaning industry on the characteristics of wet work exposures. We quantified the burden of wet work in professional office cleaning activities with a continuous standardized observation by trained observers of 41 office cleaners. Duration and frequency of wet work exposure and of different cleaning activities were assessed. Wet work made up 50% of such cleaning work. Within a typical 3-hr shift, a mean frequency of 68 episodes of wet work was observed, which classifies office cleaning as wet work. Skin exposure to irritants was markedly different among cleaners who did the same cleaning activities. Reduction in skin irritation can be achieved by training the workers. Because this group of workers, who have a low level of education, has a high risk of developing irritant hand dermatitis, a special effort on training and instruction should be made. A reduction of exposure can be achieved by: using gloves more often; using gloves for a shorter period of time; using gloves while doing activities that otherwise cause the skin to be in contact with water and cleaning substances and washing hands with water only, reserving soap for when the hands are visibly dirty.

Construction and validation of a photographic guide for assessing severity of chronic hand dermatitis

BACKGROUND

A standardized instrument is needed to rate the overall severity of chronic hand dermatitis (CHD), in particular during clinical trials.

OBJECTIVES

To design and validate a photographic guide.

METHODS

Initially, five experts were asked to grade 50 photographs of CHD, first individually, then as a consensus-building group, in order to select the photographs included in the guide. Then, a validation session with 11 different dermatologists evaluating 28 patients was conducted to assess the interrater reliability and test-retest reproducibility of the assessment of disease severity, relying on the photographic guide, on two consecutive days. Patient order was randomized, and only diseased hands were visible to prevent any bias in evaluation.

RESULTS

The experts reached a consensus for development of a photographic guide composed of five severity levels and four photographs per severity level. Results of the validation session showed a high level of interrater reliability and test-retest reproducibility.

CONCLUSIONS

The photographic guide is a reliable tool for assessing the morphological severity of hand dermatitis, and can be used as part of a comprehensive evaluation of disease in international multicentre clinical trials.

Exposure of the hands to wet work in nurses

Prevention of hand dermatitis among nurses can be achieved by reduction of wet-work exposure. A preventive programme should be based on knowledge of exposure levels. An accurate method to assess such exposure levels is needed. Duration and frequency of wet-work activities were assessed by a questionnaire, in various parts of the health care sector. In addition, a randomly chosen sample from this population was observed for the duration and frequency of wet work. In contrast to the questionnaire, the observation method showed less than half the duration of wet work. Observation detected almost double the frequency that was reported with the questionnaire. Gloves were observed to be used daily in special care units for short time periods. A questionnaire does not accurately assess the quantity of wet-work activities. On regular wards, the exposure to irritants is mainly associated with the frequency of wet hands, rather than the duration of wet hands. We assume that the short-term use of gloves on special care units does not cause an increased risk of hand dermatitis. Preventive programmes can focus on decreasing the frequency of wet hands by encouraging the use of gloves; the use of gloves should not only be advised to prevent infections but also to protect against hand dermatitis.

Skin protection in nursing work: promoting the use of gloves and hand alcohol

Nursing has been identified as a wet-work occupation, with a high prevalence of occupational irritant contact dermatitis. Reduction of exposure to skin irritants contributes to the prevention of occupational skin disease in nurses. The role of the use of soap and water, hand alcohol and gloves in prevention programmes is discussed. 2 additional measures for reducing exposure to skin irritants are postulated: use of hand alcohol instead of soap and water in disinfection procedures when the hands are not visibly dirty; use of gloves in wet activities such as patient washing to prevent the hands from becoming wet and visibly dirty. We investigated the effectiveness of these recommendations in a model. Mean daily wet-work exposure during nursing work was modelled: regular model. We also modelled exposure to skin irritants in combination with the implementation of these recommendations: prevention model. The hands of healthy volunteers were exposed to the regular or the prevention model over 3 weeks for 5 days a week. The change in transepidermal water loss (TEWL) on the back of the hands was measured after 3 weeks of exposure to these wet-work simulations. An increase in TEWL occurred with the regular model, while mean TEWL decreased in the prevention model. Skin irritation from occlusion by gloves appeared to be more pronounced in the regular model compared to the prevention model. The results of this study justify the conclusion that in nursing work, hand alcohol is the preferred disinfectant. Although the prevention model implies increased occlusive exposure, this has no additional irritant effect, probably because of the absence of soap exposure.

Overview of studies of treatments for hand eczema-the EDEN hand eczema survey

BACKGROUND

Hand eczema is a major cause of morbidity and lost earnings. Many interventions ranging from topical steroids to oral ciclosporin are used, but their evidence base and the best methods to assess their efficacy are uncertain.

OBJECTIVES

As part of a long-term project to improve standards of design and reporting in hand eczema trials, we sought to describe the prevalent study designs and comment on the quality of reporting of such studies. METHODS AND DATA SOURCES: Electronic databases (Cochrane, Medline, Embase, Pascal, Jicst-Eplus, Amed) were searched from January 1977 to April 2003 using all possible variants of the terms hand and eczema/dermatitis. In addition, four general medical and 17 specialist dermatology journals were hand-searched by pairs of researchers for all possible therapeutic studies.

STUDY SELECTION

Studies were eligible for inclusion if they dealt with hand eczema as diagnosed by a physician irrespective of the aetiology, and if they described the results of a study of a therapeutic intervention in humans. Single case reports and reviews were excluded, but case series and nonrandomized studies were considered alongside randomized studies. Data selection For each study, two researchers independently assessed the type of study, outcome measures, enrolment criteria, randomization, masking of interventions and how losses to follow-up were dealt with.

MAIN OUTCOME MEASURES

Proportion of studies according to type of intervention and study type. Proportion of randomized controlled trials (RCTs) that adequately reported eligibility criteria, randomization generation and concealment, masking and intention-to-treat analysis.

RESULTS

A total of 90 studies reported in 87 papers dealt with 11 different classes of interventions. Around 80% of the studies dealt with just four interventions: ultraviolet light, topical steroids, radiation and systemic immunosuppressives. Of the 90 studies, 44 were case series, 15 were nonrandomized controlled trials, and the remaining 31 were RCTs. Of the 31 RCTs, 16 were parallel (one with cross-over design) and 15 self-controlled. Only 11 of the RCTs adequately reported eligibility criteria. The randomization method was described in 10, and there was adequate concealment of allocation in eight. Masking the treatment allocation from both the study assessors and patients was done in 11 RCTs, and intention-to-treat analysis was reported in four. Only 13 RCTs were 4 months or longer in duration. No study reported a rationale for the sample size, and in only one study had the outcome variable been validated.

CONCLUSIONS

Most 'trials' in hand eczema are not RCTs. Internally controlled (left/right) studies were common. Based on the poor overall quality of reporting, most RCTs of hand eczema trials are not adequate to guide clinical practice. Future trials of hand eczema should be randomized, using a parallel group or self-controlled design. Research is needed to develop validated and clinically relevant outcome measures. Most of the remaining issues relating to poor quality of existing evidence can be relatively easily dealt with by following the CONSORT guidelines.

Irritant hand dermatitis: severity of disease, occupational exposure to skin irritants and preventive measures 5 years after initial diagnosis

Irritant contact dermatitis (ICD) is often chronic; its aetiology frequently being related to occupational exposure. Management of ICD involves persistent reduction in exposure to skin irritants such as water, detergents and prolonged occlusion by gloves. The aim of this study was to determine the severity of hand dermatitis 5 years after initial diagnosis and to find out what factors were related to this outcome. A questionnaire survey was carried out on severity of hand dermatitis, exposure to skin irritants and preventive measures, 5 years after initial ICD diagnosis. Of a cohort of 201 patients with ICD, 172 received the questionnaire and 124 (72%) responded. 5 years after initial diagnosis, 50% still had medium and 32% severe hand dermatitis. Patients with severe ICD and high exposure showed low levels of prevention and difficulty in changing their occupational exposure. Use of emollients was predominantly therapeutic rather than preventive. Occupation was changed in 57% of cases, of which 46% was permanent. In this population, ICD is a chronic disease; implementation of secondary preventive measures appears to fail. In occupations with high exposure to skin irritants, implementation of permanent exposure reduction is more difficult, compared to occupations with a medium level of exposure. High exposures might have led to change of occupation; medium exposures could have been reduced to low levels. In occupations with high exposure, women were overrepresented.

Lebensqualit�t bei Patienten mit berufsbedingten Handekzemen

In recent years quality of life has been studied in a growing number of different dermatological diseases. Internationally validated questionnaires such the RAND-36 (identical to the SF-36) do not contain enough questions which are relevant for skin diseases. There is no publication on quality of life issues in occupational skin diseases, and only one short report gives data on quality of life in hand eczema. The widely used skin specific instrument DLQI has only 2 questions that indirectly refer to employment issues. A quality of life questionnaire on occupational skin diseases (mostly hand eczema) should ideally include questions on work-related impairment of both physical functioning and interaction with colleagues.

Contact allergens in shoe leather among patients with foot eczema

Some patients with relapsing foot eczema and a shoe leather allergy, who fail to show positive results with standard series and shoe wear screening tray patch testing, do not respond to the use of hypoallergenic shoe leather. We assume that relevant allergens are present in hypoallergenic shoe leather. We described an experiment to demonstrate the presence of these allergens. Alcoholic extracts were made of green, black and undyed hypoallergenic shoe leather, and the extracts were fractioned by paper chromatography. The resulting chromatograms were cut into 16 equal paper disks and patch tests were performed with extracts and the paper chromatography fractions. Positive reactions were seen to all extracts and to fractions of all types of leather. From analysis of the pattern of positive patch tests we concluded that leather-related allergens (e.g. tanning agent) and dyes were present in hypoallergenic shoe leather. In these cases, alternatives to shoe leather should be sought, for instance wooden or plastic shoes.

[Intensive patient education and treatment program for young adults with atopic eczema]

BACKGROUND AND OBJECTIVE

By means of a 2-week intensive multidisciplinary training & treatment course in small groups (ISBP), young adults with atopic dermatitis may be able to achieve better self-management of their disease and reduce their number of doctor visits.

METHODS

Patients aged 18-35 with moderate to severe atopic dermatitis (SCORAD > 20) were randomized in a treatment (ISBP) group of n = 31 and a control group of n = 20. Follow-up was 9 months. The outcome was assessed using validated primary and secondary parameters, both specific for atopic dermatitis and more general.

RESULTS

Participants in the ISBP scored significantly better at follow-up in the Marburger atopic dermatitis-specific questionnaire and the self-care parameter, needed less time for medical consultations, and used more emollients without corticosteroids. Absence from work/sick leave was less at 10 weeks follow-up, but equal at 9 months.

CONCLUSIONS

The ISBP program can be judged successful because both the patients and their doctors perceive their interactions as more efficient, less time time-consuming and more satisfying.

Sensitivity, specificity and positive predictive value of patch testing: the more you test, the more you get? ESCD Working Party on Epidemiology

Pathophysiological variability affects the results of patch testing. In addition, even a minimal degree of test-imprecision due to this variability has a number of important statistical consequences for the analysis and interpretation of any patch test data set. One such statistical phenomenon that is often overlooked is the dependence of the positive predictive value (i.e., the predictive value of a positive patch test) on sensitivity and specificity, the impact of which is heavily dependent on the proportion of truly allergic subjects that are studied. A 2nd important issue is the fact that patch testing is performed in series, which means multiple tests. If we assume, for example, a patch test series of only 10 allergens, then it can be demonstrated that there is a random probability of over 40%) to find, simply by chance, for at least 1 allergen, a statistically significant difference between 2 groups of patients. Comparison of the results of series between patients calls for statistical adjustments in order to prevent erroneously positive differences and/or associations.

The epidemiology of occupational contact dermatitis

Occupational contact dermatitis (OCD) ranks first of all occupational diseases in many countries. The incidence rate is believed to be around 0.5-1.9 cases per 1000 full-time workers per year. Epidemiological studies play an important role in observing disease trends, analysing risk factors, and monitoring the effect of preventive measures. In this review article the lack of truly epidemiologic data on OCD and the difficulties of those studies are illustrated. The following issues are highlighted: case ascertainment and bias, the distribution of allergic and irritant contact dermatitis in the working population, the interrelationship between exogenous (allergens, irritants) and endogenous factors, the prognosis, the social and economic impact, and the need for intervention studies.

Blood lipid concentrations of dioxins and dibenzofurans causing chloracne

Chloracne is caused by exposure to certain halogenated polycyclic hydrocarbons such as polychlorinated dibenzodioxins (PCDDs) and dibenzofurans (PCDFs). In chronic exposure it is not known what level of intoxication, represented by the level in blood lipids, is sufficient to cause chloracne. Blood levels of the congeners of PCDD/Fs were determined in four groups of humans. One group had clinically visible chloracne due to exposure in a hexachlorobenzene workshop of a large chemical factory. A second group was exposed in the same workshop, but had no skin changes. There were two control groups: one non-exposed group of maintenance workers from the same chemical factory, and one group of healthy individuals living elsewhere. Blood levels were converted to toxicity equivalents of tetrachlorodibenzo-p-dioxin (TCDD). In the chloracne group blood levels in toxicity equivalents (TEQs) ranged from 1168 to 22,308 pg/g blood lipid. In the exposed without chloracne this ranged from 424 to 662 pg/g. It is concluded that the level to develop chloracne is between 650 and 1200 pg/g TEQ. The contribution of TCDD was rather small, and the main causative congeners were the hexachlorinated dibenzodioxins and dibenzofurans (HxCDD/Fs); lipid-based blood levels in absolute amounts that may cause chloracne are in the range of 2-3.5 ng/g HxCDD, and 2-5 ng/g HxCDF.

The management of moderate to severe atopic dermatitis in adults with topical fluticasone propionate. The Netherlands Adult Atopic DermatitisStudy Group

This study was designed to investigate a long-term therapeutic strategy for the management of recurring atopic dermatitis (AD) in adults using fluticasone propionate (FP) ointment (CutivateTM) whereby FP could help to prevent a relapse of AD once symptoms were under control. Adult patients with chronic, moderate to severe AD entered this multicentre study. All patients were initially treated with FP 0.005% (g/g) ointment in two different regimens. Patients whose AD had been completely healed by these treatments then entered a long-term treatment phase applying FP or placebo ointment once daily, two times per week for 16 weeks to 'known' healed lesions. By the end of the initial treatment period, mean SCORAD values had significantly (P < 0.0005) improved from baseline. Patients who entered the maintenance phase and were treated with intermittent FP for up to 16 weeks, demonstrated its superior efficacy (P = 0.018) over placebo, maintaining the improvements achieved after the initial treatment phase, reducing risk of relapse and delaying time to relapse (P = 0.013). No significant changes were detected in either treatment group in serum cortisol levels or in skin thickness measurements. Intermittent FP applied two times per week maintained a significant level of control, and delayed relapse of AD by comparison with placebo.

Irritancy ranking of anionic detergents using one-time occlusive, repeated occlusive and repeated open tests

Discrepancies between the one-time patch test and the wash test regarding the ranking of irritancy of detergents have been found in the literature. The aim of the present study was to investigate the concordance of irritancy rank order of 4 anionic detergents tested by 3 different exposure methods, namely one-time occlusive, repeated short-time occlusive and repeated short-time open tests. These detergents were sodium cocoyl isethionate (ISE), sodium lauryl sulfate (SLS), soap and disodium lauryl 3-ethoxysulfosuccinate (SUC). The reactions were evaluated by visual scoring and by transepidermal water loss (TEWL) measurement. When scored visually, the rank order in the one-time test was: SOAP > or = SLS > or = ISE > SUC. The other test methods yielded a different order: SLS > ISE > or = SOAP > SUC. A similar rank order was obtained with TEWL measurement for all exposure methods. Generally, the concordance among the different exposure methods was high when evaluated by TEWL. The concordance was lower when evaluation was performed by visual scoring. The present study demonstrates that the choice of exposure model and evaluation method may be important variables influencing the outcome of irritancy testing. It is proposed that the repeated open test is the best way to simulate most in-use situations where the uncovered skin is exposed to detergents. The repeated occlusive test or the one-time patch test may be better to simulate situations in which the skin is occluded after irritation by detergents.

House-dust mite hypersensitivity, eczema, and other nonpulmonary manifestations of allergy

The pathogenetic role of house-dust mites (HDM) in atopic dermatitis (AD) remains controversial, mainly because there is no common agreement on a provocation test that mimics ordinary exposure to HDM. This is related to the lack of knowledge of the mechanism of how HDM allergens enter the body. Theoretically, there are two possible routes: directly through the epidermis, or by inhalation. In "atopy patch testing", a concentrated HDM suspension is tested on the skin under occlusion. This method is frequently used as a model of the epidermal route. The clinical relevance of this method as a provocation test for AD is discussed. As opposed to atopy patch testing, we describe another method, namely, "allergen inhalation testing", as a model of the respiratory route. Twenty patients with AD underwent bronchial provocations with HDM extract in a double-blind, randomized, placebo-controlled study. In nine out of 20 AD patients, bronchial challenge with HDM evoked skin symptoms. All patients with HDM-induced dermatitis had a history of asthma, and as a group they had a higher mean total log-transformed IgE level than the "negative skin responders". Thus, the respiratory route may be relevant in the provocation of AD in a subset of AD patients and may represent an appropriate model of provocation in these patients. Furthermore, the role of HDM in urticaria and allergic rhinitis is discussed.

Risk for hand eczema in employees with past or present atopic dermatitis

Persons with atopic dermatitis run a considerable risk of developing hand eczema when exposed to occupational agents that are a burden to the skin. This also pertains to those with a history of skin atopy in childhood. This review presents estimates of the risk of developing hand eczema and examines the evidence for an effect modification by skin atopy on exposure. Skin atopy at least doubles the effects of irritant exposure and, thus, doubles the risk in occupations where hand eczema is a common problem. On the basis of this evidence, guidelines for occupational counseling can be given. Further development of a scale indicating the degree of atopic skin diathesis should facilitate the targeting of this counseling toward specific high-risk groups.

Irritancy of antiseptics tested by repeated open exposures on the human skin, evaluated by non-invasive methods

The aim of the study was to test the irritancy of 6 antiseptics in an open exposure model. The following agents were tested in their normal use concentrations using open exposures, 2x daily for 4 days in 20 subjects: chlorhexidine 4% (CH), chlorhexidine 0.5% in ethanol 70% (CE), ethanol 70% (ET), iodine 1% in ethanol 70% (IE), povidone-iodine 10% (PI) and sodium hypochlorite 0.25% (SH). Responses were evaluated by visual scoring, subjective irritancy scoring, stratum corneum hydration (Corneometer), transepidermal water loss and laser Doppler flowmetry. Exposure to SH had to be discontinued after 4 applications because of severe subjective irritation. The same held true for IE (7 applications), whereas the other agents were exposed 8x. All evaluation methods showed SH to be significantly more irritating than IE, which was in turn more irritating than CH, CE, ET and PI. Thus, it can be concluded that CH, CE, ET and PI were non-irritating in this open exposure model.

Induction of atopic dermatitis by inhalation of house dust mite

BACKGROUND

The pathogenetic role of house dust mite in atopic dermatitis remains controversial. Recent studies have shown that intensive epicutaneous contact of house dust mite allergen with premanipulated skin may induce dermatitis. It is, however, uncertain whether such conditions are met during natural contact with house dust mite. In the past, allergen inhalation has been suggested to induce exacerbation of atopic dermatitis. The aim of this study was to investigate whether dermatitis could be induced in patients with atopic dermatitis by inhalation of house dust mite.

METHODS

Twenty patients with atopic dermatitis underwent bronchial provocations with house dust mite. Challenge tests were performed with four concentrations of a standardized house dust mite extract in a double-blind, randomized, placebo-controlled fashion. Spirometry was performed, and FEV1 was measured before and after each challenge dose. Changes in severity or localization of itching or erythema were recorded.

RESULTS

In nine of 20 patients with atopic dermatitis bronchial challenge with house dust mite induced unequivocal skin symptoms after 1.5 to 17 hours. Pruritic erythematous lesions on noninvolved sites together with exacerbations of existing lesions were seen in three patients. Three patients had an exacerbation only, and three other patients had new lesions only. In eight of nine patients with house dust mite inhalation-induced dermatitis, skin symptoms were preceded by an early bronchial reaction. All patients with house dust mite-induced dermatitis had a history of asthma, and as a group they had a higher mean blood total IgE level compared with the "negative skin responders." One patient had pruritic erythema on the placebo challenge day, without a preceding bronchoconstrictive reaction. The number of patients who had a skin response on the house dust mite challenge day was significantly higher than the number of patients who had a skin response on the placebo day (p = 0.011 [Prescott's test]).

CONCLUSIONS

The respiratory route may be relevant in the induction and exacerbation of dermatitis in a subset of patients with atopic dermatitis who have early bronchial reactions after house dust mite inhalation, a history of asthma, and an elevated blood total IgE level. Furthermore, these findings suggest a possible causal relationship between bronchial reactions and skin reactions.

Measurement of transepidermal water loss in Tanzanian cot-nursed neonates and its relation to postnatal weight loss

In healthy cot-nursed Tanzanian neonates (n = 92, gestation 26-42 weeks) measurements of trans-epidermal water loss (TEWL) and weight change were performed during the first 24 h after birth at an average ambient humidity of 70% and an environmental temperature of 32 degrees C. Urine production on day 1 (ml/kg per 24 h) was documented for a subgroup of 13 preterm and 8 term infants. In a limited group of preterm infants (n = 5) TEWL measurements, weight and 24 h urine volume measurements were repeated daily for 7 days. Maximum weight loss was determined in 7 preterm (gestational age 30-36 weeks) and 6 term infants. TEWL was estimated by measuring the evaporation rate at three sites of the body using the water vapour pressure gradient method. On day 1, TEWL was highest in the most preterm infants, whereas TEWL and urine production were higher in large for gestational age infants as compared to appropriate for gestational age (AGA) infants of the same gestational age (31-36 weeks). For the whole group, weight loss on day 1 was correlated with TEWL (r = 0.49, p < 0.05). At follow-up TEWL in preterm infants remained almost constant during the first 4 days and decreased after the fourth day, at which time weight gain commenced. Preterm AGA infants (gestational age 24-37 weeks) showed a mean postnatal weight loss of 4.4% of the birth weight, while in term infants this loss was only 2.6%. A reduced postnatal weight loss as compared to Caucasian infants may be explained by a lower water loss during the first days after birth, through both skin evaporation and urine excretion.

Methyldibromoglutaronitrile is an important contact allergen in The Netherlands

From 15 May to 15 December 1994, 2943 patients suspected of having contact dermatitis (1955 women, 988 men) were patch tested with methyldibromoglutaronitrile 0.3%, 0.1% and 0.05% pet. 119 patients (4.0%; women 4.1%, men 3.8%) proved to be allergic. 71% of the reactions were considered to be relevant. In 2/3 of the patients, causative products were cosmetics, in 1/3 moistened toilet tissues. Testing with methyldibromoglutaronitrile at lower concentrations (0.05% and 0.1%) and with commercial allergens (Euxyl K 400 and methyldibromoglutaronitrile, both containing methyldibromoglutaronitrile 0.1%), resulted in a number of false-negative reactions. All preservatives in the European standard series had lower scores than the 4% positive reactions to methyldibromoglutaronitrile (formaldehyde 2.0%, MCI/MI (Kathon CG) 3.2%, parabens 1.0%, quaternium-15 1.3%). It is concluded that methyldibromoglutaronitrile (present in the commercial preservative Euxyl K 400) is an important contact allergen in the Netherlands in cosmetics and moistened toilet tissues. It should be added to cosmetics series and to proctological series. The optimal test concentration is unknow, but may be 0.3% pet. The concentration of 0.1% methyldibromoglutaronitrile in the currently available commercial allergens appears to be too low, resulting in a number of false-negative reactions.

Irritant susceptibility and weal and flare reactions to bioactive agents in atopic dermatitis. II. Influence of season

Many atopic dermatitis (AD) patients have exacerbations of their skin disease in winter. These exacerbations may be caused by non-immunological 'non-specific' factors, such as low sun exposure and low temperature. To date, the influence of season on non-specific skin reactivity in AD has not been studied. The aim of the present investigation was to assess the influence of season on two skin parameters which may be used as quantitative measures of non-specific skin reactivity in AD: (i) susceptibility to repeated epicutaneous irritant (sodium lauryl sulphate, SLS) exposure, and (ii) weal and flare responses to intracutaneous injection of bioactive agents (codeine, FMLP, histamine, methacholine, substance P, trypsin). Four of 16 AD patients had dermatitis which was more severe in November than in July. Susceptibility to SLS was increased in November, both in AD patients and in control subjects. AD patients were more susceptible to SLS than control subjects in both July and November. Pre-exposure barrier function and skin hydration were reduced in November. The increased irritant susceptibility in November may be attributed to reduced barrier function, reduced skin hydration, and/or absence of the beneficial effects of ultraviolet light on cellular targets beneath the stratum corneum. Flare responses to codeine, methacholine, substance P and trypsin were also increased in November compared with July, especially in AD patients. However, smaller flares were observed in AD patients than in control subjects, in both July and November. Flare values were negatively correlated with dermatitis severity, probably because of down-regulation. Weal responses did not show a clear seasonal variation. Hence, susceptibility to epicutaneous irritants and reactivity to intracutaneously injected bioactive agents are parameters which may be used to monitor season-dependent changes in non-specific skin reactivity.