Routine patch testing with frullanolide mix: an European Environmental and Contact Dermatitis Research Group multicentre study

Contact sensitivity to plants containing 1 or more sesquiterpene lactones (SLs) is difficult to diagnose. The mixture of SLs (SL mix) has been shown to detect only about 60% of sensitized individuals. In order to improve the diagnosis of sensitization to plants containing SLs, we have tested a mixture of frullanolides contained in Frullania dilatata and Frullania tamarisci at 3 different concentrations (0.01%, 0.033% and 0.1% in petrolatum). 8605 consecutive eczema patients in 1 North American and 15 European dermatology departments were tested with this mix, and 0.35% of positive cases to the different concentrations were found. Routine use of this mix permitted detection of only a small percentage of extra cases and did not improve the SL mix score. The frullanolide mix should therefore be restricted to investigations in particular geographical zones and/or in particular occupations.

Principles and methodology for identification of fragrance allergens in consumer products

Fragrances contain several hundreds of different chemicals, a few major and many minor, which are responsible for the complexity of the odour. Fragrances are a major cause of allergic contact dermatitis. As a diagnostic tool, the current fragrance mix is very useful though not ideal. A 50-year-old woman presented with a pruriginous, erythematous eruption, characterized by papules, vesicles, exudation and crusting over the neck and chest. With the suspicion of fragrance allergy, patch testing was performed. Initially, the only positive reaction observed was with her own eau de toilette named Woman. The TRUE Test fragrance mix patch test was negative. Chemical fractionation of Woman perfume concentrate was combined with a sequenced patch testing procedure and with structure-activity relationship studies. Ingredients supplied by the manufacturer were also included in the study. Benzophenone-2, Lyral, alpha-hexyl cinnamic aldehyde and alpha-damascone were found to be responsible for the patient's contact allergy to the commercial product. These substances contain chemical structural alerts giving them antigenic ability. The common use of new chemicals to manufacture fragrances, and the increased number of patients sensitive to them but with negative fragrance mix reactions, makes it necessary to identify new potential fragrance sensitizers in commercial products.

Metal-induced generalized pruriginous dermatitis and endovascular surgery

Metal contact allergy is a common problem in the general population. Diagnostic and therapeutic medical-surgical procedures in which metals can be responsible for eczema are diverse. Endovascular aortic surgery is still an experimental but less invasive technique. A generalized eczematous dermatitis elicited by metal of an endovascular prosthesis is presented. An abdominal aortic aneurysm was diagnosed in a 79-year-old woman. Endoluminal repair with a straight Vanguard endograft was successful. 3 weeks later, she suffered a severe episode of erythema and eczema on the legs. Since then, she complained of continuous pruritus with eczema and excoriated papules. The dermatitis and also the patch test pathology showed eczema. Patch testing was positive to nickel sulfate and cobalt chloride. An endograft semi-quantitative metal analysis was performed with plasma-induction joint mass-spectrometry. The self-expanding metal stent was mainly composed of nickel (approximately 55%) and titanium (21%) with reinforcing thread of platinum. Antimony was detected only in the polyester textile. These results are consistent with Nitinol composition. The need for preoperative patch testing for metals is controversial. Enquiry about metal allergy is recommended before endoluminal surgical procedures. In the near future, the design of endografts must take into account the possibility of this sort of reaction.

Patch testing with corticosteroid mixes in Europe. A multicentre study of the EECDRG

This study investigated whether a corticosteroid mix containing tixocortol pivalate, budesonide, and hydrocortisone-17-butyrate could detect contact allergy to corticosteroids. 2 corticosteroid mixes, 1 with a high (mix I) and 1 with a low (mix II) concentration and the 3 individual constituents, each at 2 concentrations, were inserted into the standard series of 16 participating clinics. Tests were read on day (D) 3 or 4. 5432 patients were tested, and 110 (2.0%) had positive reactions to at least 1 of the 8 test preparations. Of the 8 preparations, mix I identified most allergic patients, followed by mix II, budesonide 0.10%, budesonide 0.002%, and tixocortol pivalate, both concentrations (1.0 and 0.10%) tracing the same number. With the mixes, 53.2-59.6% of tixocortol pivalate allergy was missed. 47 patients were allergic to either concentration of tixocortol pivalate, 25% of these only to 1.0% and another 25% only to 0.10%. Testing with mix I and tixocortol pivalate 0.10% picked up 98/110, testing with tixocortol pivalate 1.0% and 0.10% and budesonide 0.10% picked up 105/110. 3379 patients were read on both D3 or D4 as well as on D7. Without a late reading (D7), up to 30% of contact allergy to corticosteroid markers was missed.

[New advances in contact allergology]

In October 1996, dermatologists commemorated the centenary of the Patch test that Jadassohn had developed in 1896 at Breslau. A great amount of scientific information came to light in the following years due to progress in immunology applied to dermatology. To consider the most important recent advances in the field of contact allergic dermatitis, it is necessary to recognise the role of adhesion molecules specific for antigen presenting dendritic cells, also keratinocytes as antigen presenting cells, the importance of CD8 cells, IL10, IL12 and IL1 and their role in modulation of the contact allergy reaction. The chemistry of haptens should lead to a decision as to whether a new molecule is allergic or not, as well as the different possibilities of bonding to form sensitizing complexes. Epidemiology and the present development of epicutaneous tests are at the centre of studies that are mentioned in this general review.

Patch testing with fragrances: results of a multicenter study of the European Environmental and Contact Dermatitis Research Group with 48 frequently used constituents of perfumes

The objective of this study was to determine the frequency of reactivity to a series of commonly used fragrances in dermatological patients. A total of 48 fragrances (FF) were chosen, based on the publication of Fenn in 1989 in which the top 25 constituents of 3 types (1. perfumes, 2. household products, 3. soaps) of 400 commercial products on the US market had been determined. In a pilot study on a total of 1069 patients in 11 centres, the appropriate test concentration and vehicle were examined. For most fragrances, 1% and 5% were chosen, and petrolatum proved to be the best vehicle in comparison to isopropyl myristate and diethyl phthalate. In the main study, a set of 5 to 10 fragrances at 2 concentrations was patch tested in each centre on a minimum of 100 consecutive patients seen in the patch test clinic. These patients were also patch tested to a standard series with the 8% fragrance mix (FM) and its 8 constituents. In patients with a positive reaction to any of the 48 FF, a careful history with regard to past or present reactions to perfumed products was taken. A total of 1323 patients were tested in 11 centres. The 8% FM was positive in 89 patients (8.3% of 1072 patients). Allergic reactions to the constituents were most frequent to oak moss (24), isoeugenol (20), eugenol (13), cinnamic aldehyde (10) and geraniol (8). Reactions read as allergic on day 3/4 were observed only 10X to 7 materials of the new series (Iso E Super (2), Lyral (3), Cyclacet (1), DMBCA (1), Vertofix (1), citronellol (1) and amyl salicylate (1)). The remaining 41 fragrances were negative. 28 irritant or doubtful reactions on day 3/4 were observed to a total of 19 FF materials (more than 1 reaction: 5% citronellol (2), 1% amyl salicylate (2), 1% isononyl acetate (3), 0.1% musk xylol (2), 1% citral (2), and 1% ionone beta (2)). Clinical relevance of positive reactions to any of the FF series was not proved in a single case. This included the 4 reactions in patients who were negative to the 8% FM. In conclusion, the top 25 fragrances commonly found in various products caused few reactions in dermatological patients and these few appeared to be clinically irrelevant, with the possible exception of Lyral. However, this data should be interpreted in the light of the relatively small number of patients tested (only 100 in most centres).

The European standard series. European Environmental and Contact Dermatitis Research Group (EECDRG)

Changes to the European standard series which have taken place since the last officially recommended alterations in 1988, are explained. New to the series is the sesquiterpene lactone mix. The PPD black rubber mix and the quinoline mix have been replaced by single components; one of the p-hydroxybenzoates has been left out of the paraben mix. Ethylenediamine dihydrochloride has been dropped from the series.

Testing with fragrance mix. Is the addition of sorbitan sesquioleate to the constituents useful?

In a multicentre study, the value of adding sorbitan sesquioleate (SSO) to the constituents of the 8% fragrance mix (FM) was investigated. In 7 centres, 709 consecutive patients were tested with 2 types of FM from different sources, its 8 constituents with 1% SSO, its 8 constituents without SSO, and 20% SSO. 5 patients (0.71%) reacted to the emulsifier SSO itself, read as definitely allergic on day 3/4. 53 patients reacted to either one of the mixes with an allergic type of reaction. When tested with the constituents without SSO, 41.5% showed an allergic reaction versus 54.7% with SSO. If both types of reactions were considered (allergic and irritant) 38.3% of 73 patients showed a positive "breakdown" result without SSO, versus 54.8% with SSO. The differences were statistically significant. Reactivity to FM constituents was changed in a specific pattern by addition of SSO--irritant reactions increased, particularly for cinnamic alcohol, eugenol, geraniol, oak moss and hydroxycitronellal, whereas others showed only a slight change. Allergic reactions were also increased by SSO, but the rank order of the top 3 sensitizers (isoeugenol, oak moss and eugenol) did not change. Cinnamic alcohol was the only constituent with decreased reactivity after addition of SSO. A positive history of fragrance sensitivity (HFS) was clearly associated with a positive allergic reaction to either the mix or 1 of its constituents (51% versus 28.6% with a negative HFS). Irritant reactions were linked to a negative HFS in a high proportion (64.3%).(ABSTRACT TRUNCATED AT 250 WORDS)

Allergic reactions to a hairdressers' series: results from 9 European centres. The European Environmental and Contact Dermatitis Research Group (EECDRG)

To obtain data on the frequency of sensitization among European hairdressers, the patch test results from 9 centres were evaluated. 8 allergens recommended by the ICDRG and EECDRG in the hairdressing series and PPD from the standard series were used to patch test 809 hairdressers and 104 clients suspected of contact sensitization. Among hairdressers, the mean frequencies of sensitization ranked as follows: GMT 19%, PPD 15%, APS 8%, PTD 8%, ONPPD 4% and PADH 4%. In contrast to GMT in acid permanent waves, the frequency of sensitization to AMT in alkaline permanent waves was only 4%. Frequencies of sensitization to pyrogallol and resorcinol were 0.8% and 0.6%, respectively. The frequencies of sensitization showed marked regional variations, particularly that to GMT, which was highest in Germany (51%), followed by Spain (22%) and London (19%). Clients of hairdressers showed a similar rank order of sensitization frequency, with the exception of APS, which was completely negative in this (small) series.

Reduced frequency of nickel allergy upon oral nickel contact at an early age

From animal studies we know that oral administration of T-dependent antigens before sensitization effectively induces systemic immune unresponsiveness. Such 'oral tolerance' is persistent, dose-dependent, antigen-specific and presumably T suppressor cell-mediated. Oral tolerance induction could be an effective way to prevent undesired T cell-mediated immune functions, such as playing a role in allograft reaction, autoimmune and allergic diseases. In the present study allergic contact hypersensitivity (ACH) to nickel, currently presenting the most frequent contact allergy in man, was chosen to establish the feasibility of oral prevention of undesired T cell-mediated immunity in man. Potentially tolerizing (oral nickel contacts via orthodontic braces) as well as sensitizing (ear piercing) events were studied retrospectively in 2176 patients attending nine European patch test clinics. Patients were interviewed by means of a confidential questionnaire. The results show that ear piercing strongly favoured development of nickel ACH. More importantly, patients having had oral contacts with nickel-releasing appliances (dental braces) at an early age, but only if prior to ear piercing, showed a reduced frequency of nickel hypersensitivity. Frequencies of other hypersensitivities, in particular to fragrance, were not affected. These results support our view that induction of specific systemic immunologic tolerance by timely oral administration of antigens is feasible in man.

Patch testing with the "sesquiterpene lactone mix": a marker for contact allergy to Compositae and other sesquiterpene-lactone-containing plants. A multicentre study of the EECDRG

6278 patients were patch tested with a sesquiterpene lactone mix (SL-mix) in 10 European clinics. 4011 patients were tested only with 0.1% SL-mix, 63 (approximately 1.5%) of whom were positive, with 26 (41%) of these cases being considered clinically relevant. There were no cases of active sensitization, though 5 cases of irritation were reported. 22 irritant reactions and 22 cases of active sensitization occurred when testing also with 1% and 0.33% concentrations of SL-mix. SL-mix 0.1% pet. is shown to be an important patch test and many relevant sensitizations will be missed without routine screening with such a mix. Most patients with SL-mix sensitivity presented with hand and/or face dermatitis, apparent photodermatitis or more generalised eczema.

Contact allergy to Bronopol

A total of 8149 patients were patch tested with the preservative Bronopol in 7 European contact clinics. The majority of patients (6507) were investigated in London. Reactivity was low, with a total of 10 irritant (0.12%) and 38 allergic reactions (0.47%). In only 17 cases (0.21%) was the patch test reaction to Bronopol considered to be of current or past clinical relevance. Concomitant sensitization to formaldehyde was present in about 1/3 of patients. Based on these figures, the present sensitization rate to Bronopol in Europe seems to be quite low, which may be related to its less frequent use as a preservative in cosmetics and medicaments in comparison to parabens or isothiazolinones.

Analgesic spray contact dermatitis

The author describes two patients with acute contact allergy to 3-(aminomethyl)-pyridyl salicylate in an analgesic spray. In one case, the patient reacted when someone used the spray not far from her.

Allergic contact dermatitis from 3-(aminomethyl)-pyridyl salicylate

2 patients with acute allergic contact dermatitis from 3-(aminomethyl)-pyridyl salicylate are described. Both patients were females with histories of urticaria and showed cross-sensitization to substances of the para group. Clinical manifestations included eczema, angioedema and respiratory effects. In 1 patient, airborne elicitation was suspected. A lymphocyte transformation test confirmed the allergy, with an extremely high response index. 35 normal controls were negative.