2-Hydroxyethyl methacrylate (HEMA): A clinical review of contact allergy and allergic contact dermatitis. Part 2. Cross- and co-sensitization, other skin reactions to HEMA, position of HEMA among (meth)acrylates, sensitivity as screening agent, presence of HEMA in commercial products and practical information on patch test procedures

This is the second part of a literature review of the clinical aspects of contact allergy to and allergic contact dermatitis from 2-hydroxyethyl methacrylate (HEMA). Topics include cross- and co-sensitization, atypical manifestations of contact allergy, frequency of positive patch tests to HEMA compared with other (meth)acrylates, sensitivity of HEMA as a screening agent, the presence of HEMA in commercial products, and practical information on patch testing procedures. Primary sensitization to methacrylates including HEMA may result in methacrylate and acrylate cross-sensitization. There is a strong cross-allergy between HEMA, ethylene glycol dimethacrylate (EGDMA), and hydroxypropyl methacrylate; many reactions to EGDMA are cross-reactions to primary HEMA sensitization. Rare atypical manifestations of HEMA-allergy include lichen planus, lymphomatoid papulosis, systemic contact dermatitis, leukoderma after positive patch tests, and systemic side effects such as nausea, diarrhoea, malaise, and palpitations. The occurrence of respiratory disease caused by methacrylates such as asthma is not infrequent. HEMA is the most frequently patch test-positive methacrylate. It is a good screening agent for allergy to other (meth)acrylates. Patch test sensitization to HEMA 2% pet. is extremely rare. There are (some) indications that HEMA is frequently used in dental products and nail cosmetics.

2-Hydroxyethyl methacrylate (HEMA): A clinical review of contact allergy and allergic contact dermatitis-Part 1. Introduction, epidemiology, case series and case reports

2-Hydroxyethyl methacrylate (HEMA) has been increasingly recognised as a contact allergen and was added to the European baseline series in 2019. In this article (2 parts), the results of an extensive literature review of the clinical aspects of contact allergy/allergic contact dermatitis to HEMA are presented. In part 1, the epidemiology of HEMA contact allergy is discussed and detailed information on published case series and case reports presented. HEMA is an important cause of contact allergy/allergic contact dermatitis in North America and Europe with recent prevalences of >3% in the USA + Canada and 1.5%-3.7% in Europe. Currently, most cases are caused by nail cosmetics, both in consumers and professional nail stylists. In our literature review, we have found 24 studies presenting case series of patients with allergic contact dermatitis attributed to HEMA and 168 case reports. However, the presence of HEMA in the products causing ACD was established in only a minority. Part 2 will discuss cross- and co-sensitisation, and other skin reactions to HEMA, will assess whether HEMA is the most frequent (meth)acrylate allergen and how sensitive HEMA as a screening agent is, investigate the presence of HEMA in commercial products and provide practical information on patch testing procedures.

Patch testing in Drug reaction with eosinophilia and systemic symptoms (DRESS): a literature review

The literature on positive patch test results in drug reaction with eosinophilia and systemic symptoms (DRESS) is reviewed. 105 drugs were identified that have together caused 536 positive patch tests in 437 patients suffering from DRESS. By far most reactions (n=145) were caused by carbamazepine, followed by amoxicillin, isoniazid, phenytoin, ethambutol, fluindione, phenobarbital, rifampicin, and ceftriaxone; 43 drugs each caused a single case only. The drug classes causing the highest number of reactions are anticonvulsants (39%), beta-lactam antibiotics (20%), antituberculosis agents (11%), non-beta-lactam antibiotics (6%) and iodinated contrast media (5%). The sensitivity of patch testing (percentage of positive reactions) is high for anticonvulsants (notably carbamazepine), beta-lactam antibiotics (notably amoxicillin) and possibly iodinated contrast media. Allopurinol and sulfasalazine frequently cause DRESS, but never give positive patch tests. Patch testing in DRESS appears to be safe, although mild recurrence of DRESS symptoms, mostly skin reactions, may not be rare. Multiple drug hypersensitivity was found to occur in 16% of all patients, but it is argued that the true frequency is (far) higher. Clinical aspects of DRESS, including diagnosing the disease and identifying culprit drugs (patch tests, intradermal tests, in vitro tests, challenge tests) are also provided, emphasizing the role of patch testing. This article is protected by copyright. All rights reserved.

Results of patch testing in Acute generalized exanthematous pustulosis (AGEP): a literature review

The literature on positive patch test results in acute generalized exanthematous pustulosis (AGEP) is reviewed. 93 drugs were identified that have together caused 259 positive patch tests in 248 patients suffering from AGEP. The drug classes causing the highest number of reactions are beta-lactam antibiotics (25.9%), other antibiotics (20.8%), iodinated contrast media (7.3%) and corticosteroids (5.4%), together accounting for nearly 60% of all reactions. The highest number of reactions to individual drugs was to amoxicillin (n=36), followed by pristinamycin (n=25), diltiazem (n=14), amoxicillin-clavulanic acid (n=13), clindamycin (n=11) and iomeprol (n=8); 59 of the 93 drugs each caused a single case only. The "Top-10" drugs together caused over 50% of all reactions. The sensitivity of patch testing (percentage of positive reactions) in patients with AGEP is largely unknown, but may generally be around 50%, which also applies to pristinamycin. Patch testing in AGEP appears to be safe, although mild recurrence of AGEP skin symptoms or other rashes may occur occasionally. Clinical aspects of AGEP, including epidemiology, etiology and pathophysiology, clinical features, histology, treatment, and prognosis are briefly presented, as are diagnosing the disease and identifying the culprit drugs with patch tests, intradermal tests, in vitro tests, and challenge tests. This article is protected by copyright. All rights reserved.

Systemic allergic dermatitis (systemic contact dermatitis) from pharmaceutical drugs: A review

The literature on systemic allergic dermatitis (SAD; also known as systemic contact dermatitis) is reviewed. Both topical drugs (from absorption through mucosae or skin) and systemic drugs (oral, parenteral, rectal) may be responsible for the disorder. The topical route appears to be rare with 41 culprit topical drugs found to cause SAD in 95 patients. Most reactions are caused by budesonide (especially from inhalation), bufexamac, and dibucaine. SAD from systemic drugs is infrequent with 95 culprit drugs found to cause SAD in 240 patients. The drugs most frequently implicated are mitomycin C, methylprednisolone (salt, ester), and hydrocortisone (salt). The largest group of culprit drugs consisted of corticosteroids (19%), being responsible for >30% of the reactions, of which nearly 40% were not caused by therapeutic drugs, but by drug provocation tests. The most frequent manifestations of SAD from drugs are eczematous eruptions (scattered, widespread, generalized, worsening, reactivation), maculopapular eruptions, symmetrical drug-related intertriginous and flexural exanthema (SDRIFE [baboon syndrome]) and widespread erythema or erythroderma. Therapeutic systemic drugs hardly ever cause reactivation of previously positive patch tests and infrequently of previous allergic contact dermatitis. The pathophysiology of SAD has received very little attention. Explanations for the rarity of SAD are suggested.

Side-effects of henna and semi-permanent 'black henna' tattoos: a full review

Henna, the dried and powdered leaf of Lawsonia inermis, is widely used as a dye for the skin, hair, and nails, and as an expression of body art, especially in Islamic and Hindu cultures. As it stains the skin reddish-brown, it is also called red henna. Black henna is the combination of red henna with p-phenylenediamine (PPD), and is used for temporary 'black henna tattoos'. This article provides a full review of the side-effects of topical application of red and black henna, both cutaneous (allergic and non-allergic) and systemic. Red henna appears to be generally safe, with rare instances of contact allergy and type I hypersensitivity reactions. In children with glucose-6-phosphate dehydrogenase deficiency, topical application of henna may cause life-threatening haemolysis. Black henna tattoos will induce contact allergy to its ingredient PPD at an estimated frequency of 2.5%. Once sensitized, the patients may experience allergic contact dermatitis from the use of hair dyes containing PPD. There are often cross-reactions to other hair dyes, dyes used in textiles, local anaesthetics, and rubber chemicals. The sensitization of children to PPD may have important consequences for health and later career prospects. Systemic toxicity of black henna has been reported in certain African countries.

Determination of formaldehyde in formaldehyde-releaser patch test preparations

BACKGROUND

Positive patch test reactions to formaldehyde-releasers in patients co-reacting to formaldehyde are often ascribed to formaldehyde allergy. However, the formaldehyde content of patch test materials has not been investigated.

OBJECTIVES

To demonstrate and quantify free formaldehyde in commercial patch test materials and in prepared aqueous solutions of formaldehyde releasers.

MATERIALS

Free formaldehyde was measured by (13)C NMR Spectroscopy in (i) all formaldehyde-releasers in water available from Chemotechnique and Brial, (ii) 5 releasers in petrolatum, (iii) 12 prepared aqueous solutions of formaldehyde-releasers and (iv) water that had been in contact with petrolatum test samples.

RESULTS

In none of the five petrolatum test substances was free formaldehyde found. In all nine commercial aqueous patch test substances and 9 of the 12 prepared solutions, free formaldehyde was demonstrated with concentrations ranging from 0.019% to 0.37% (detection limit 0.01%). Contact of the petrolatum test samples with water resulted in the release of formaldehyde.

CONCLUSIONS

Most aqueous solutions of formaldehyde-releasers contain free formaldehyde. Petrolatum-based patch test materials with formaldehyde-releasers do not contain free formaldehyde, but probably start releasing it upon contact with water. Therefore, in future studies, determination of free and releasable formaldehyde may be preferable.

Frequency of sensitization to common allergens: comparison between Europe and the USA

BACKGROUND

Previously, contact allergy to formaldehyde and quaternium-15 was found to be more prevalent in the United States than in Europe. No such data have been assessed for other contact allergens.

OBJECTIVE

Determine any differences in frequencies of sensitization to contact allergens in the United States and Europe.

METHODS

Literature study. Comparison of reported frequencies of sensitization to contact allergens routinely tested both in the United States and Europe in recent, large, multicentre studies. Because of the heterogeneity of studies and background parameters, statistical evaluation was not attempted.

RESULTS

Major differences were found only for neomycin (USA 10.0-11.8%, mean 11.4%; Europe 1.2-5.4%, mean 2.6%). Most allergens had somewhat higher prevalence in the United States, with rates versus Europe ranging from 1.3 to 1.9.

CONCLUSIONS

Contact allergy to neomycin is much more prevalent in the United States. Stricter selection of patients for patch testing in United States tertiary referral centres may result in 50% more positive reactions compared to European studies.

Formaldehyde-releasers in cosmetics in the USA and in Europe

BACKGROUND

Frequencies of sensitization to formaldehyde among US patients patch tested for suspected contact dermatitis are higher than in Europe. Cosmetics are an important source of contact with formaldehyde.

OBJECTIVES

To acquire data on the frequency of use of formaldehyde-releasers in cosmetics sold in the USA and Europe and their use concentrations. To assess whether any observed differences may contribute to the discrepancies in sensitization rates.

METHODS

Enquiries with Food and Drug Administration (FDA), the European Cosmetics Association, and the Dutch Cosmetics Association. Reading the labels of skin care cosmetics in a local drugstore.

RESULTS

The FDA provided data on the presence of formaldehyde and releasers. Nearly one fifth of all cosmetics contain a releaser. In 25% of 496 examined skin care products, releasers were present. In comparable FDA data categories, the percentage was 24. No data were found on use concentrations of the releasers in cosmetics in either the USA or Europe.

CONCLUSIONS

The percentages of stay-on skin care products containing a formaldehyde-releaser are virtually identical in the USA (FDA data) and our local drugstore sample. However, this does not necessarily imply that cosmetics play no part in the differences in formaldehyde sensitization rates.