Acrylics Update

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Voller LM, Warshaw EM. Acrylates: new sources and new allergens. Clin Exp Dermatol. 2020;45(3):277-283. doi:10.1111/ced.14093

Reviewed by Jalal Maghfour and Alina Goldenberg MD

Acrylates, a group of synthetic thermoplastic resins, are becoming essential in industrial societies; they are commonly found in various nail products, adhesives, insulators, paints and windshields. Acrylates are known to cause allergic contact dermatitis (ACD) with the first documented case dating from 1941. ACD resulting from acrylates has been well-documented in the literature. In fact, acrylates were listed as the 2012 allergen of the year by the American Contact Dermatitis Society (ACDS).

Given the emergence of new sources of acrylates the aim of this synopsis is to highlight ACD associated with non-occupational and occupational acrylates exposure.

Non-occupational ACD secondary to acrylate exposure has been commonly reported. In 1995, Isobornyl acrylate (IBOA) was first documented to induce ACD during insulin infusion pump. Most recently, IBOA was isolated from the adhesives used primarily in many medical devices such as insulin pump and glucose monitors. This has resulted in IBOA becoming recognized as the 2020 allergen of the year by ACDS. Thus, diabetic patients and healthcare providers are particularly vulnerable to ACD due to IBOA.  

Acrylates contained in various artificial nail preparations are also a major source of sensitization. Cyanoacrylates are used in cosmetic and medical glues. There have been reports of ACD due to Dermabond which is a common surgical glue, due to its 2-octyl and cyanoacrylate ingredients.  

Occupational exposure to acrylates is also frequent.  Nail technicians are at high risk for developing acrylate allergy. Other fields such as orthodontists and dental technicians may be at increased risk for developing ACD given that the wide use of methacylates in dental prostheses.

As with any ACD, patch testing remains the gold standard diagnostic modality. Once an acrylate sensitization is diagnosed, patients should be adequately counseled on avoiding any cosmetic or industry products that contain acrylates. Workers at high-risk of exposure are recommended to wear trilaminated polyethylene gloves which  confer protection up to 4 hours. 

PPD– Still a menace

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Alina Goldenberg MD, Sharon Jacob MD. Paraphenylenediamine in black henna temporary tattoos: 12-year Food and Drug Administration data on incidence, symptoms, and outcomes. Journal of American Academy of Dermatology. April 201

https://www.jaad.org/article/S0190-9622(14)02217-8/abstract

Review by: Jalal Maghfour and Alina Goldenberg MD

Paraphenylenediamine (PPD) continues to be the main oxidizing agent widely utilized in the US for hair dyeing.  One of the major advantages of PPD, particularly in dark shades, is the resulting long-lasting color and the “natural” look that many individuals seek to achieve.

Given that PPD has been recognized as a strong sensitizing agent for several decades, it is solely approved for hair dye use with a concentration limited to 6%.

In the past decade, adverse reactions due to PPD have been on the rise; this has been seen primarily  when high amounts of PPD is mixed with black henna tattoos, which is a popular form of tattooing among travelers, as it is cheap and easy to remove. The addition of PPD to black henna offers a darker color that is appealing to costumers and enables a faster speeding dyeing process.

Yet, the physical and mental costs associated with local and systemic adverse effects of PPD are high and can be severely debilitating. Herein, the aim of this synopsis is to review the incidence, symptomatology and outcome among PPD-laced henna black tattoo users.

Even though PPD is limited to 6% in hair dye, it has been reported that black henna tattoo products may contain PPD concentrations of up to 30%. It is therefore not surprising that many individuals experience cutaneous reactions to PPD. In majority of cases, allergic contact dermatitis (ACD) including erythema, pruritus, and vesicular/bullous dermatitis may occur (67%). It is important to note that a primary sensitization to PPD is required for ACD to occur following a subsequent re-exposure. In addition, urticarial dermatitis was also reported as an adverse reaction (17%). The latter is a rare form of contact dermatitis that is mediated by an IgE induced mast cell degranulation resulting in hives and wheels. This type of dermatitis is highly concerning as it has been linked to anaphylactic shock.

It is also important to note that beyond localized reactions seen with PPD, systemic toxicity may also occur. Indeed, prolonged cutaneous exposure, at small or large doses for a long period of time, can result in systemic toxicity similar to the toxicity profile reported with PPD ingestion. A wide array of symptoms may be seen and can include the following: angioedema, acute hepatotoxicity, rhabdomyolysis, renal failure, neuropathy, blindness, and death.

Given the spike in severe cases of PPD laced black henna reactions reported by patients worldwide, Dermatitis, the official journal of the American Contact Dermatitis Society (ACDS), has listed PPD as the allergen of the year for 2006. In 2008, both ACDS and American Academy of Dermatology (AAD) officially opposed against the continuous use of PPD-laced black henna. This action has resulted in an increase in both physician and community member awareness as reflected by a lower number of reported cases following the joint ban from highly respected organizations.  

This commentary highlights not only the serious adverse effects of PPD but also puts into perspective the central role dermatologists and dermatology organizations can have in public awareness and education by advocating for patients’ safety.

What is essential in essential oil?

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Reeder MJ. Allergic Contact Dermatitis to Fragrances. Dermatol Clin. 2020;38(3):371‐377. doi:10.1016/j.det.2020.02.009

Reviewed by Jalal Maghfour and Dr. Alina Goldenberg, MD

https://www.webmd.com/beauty/news/20180813/essential-oils-promise-help-but-beware-the-risks
https://www.poison.org/articles/2014-jun/essential-oils

Essential oils (EOs) are the quintessential oils in flowers, stems, seeds, leaves, roots and berries.  Although the name “essential” may imply purity, in reality, EOs are processed hydrophobic volatile compounds from raw plant material with various stabilizing additives.  Nevertheless, since ancient times, EOs have been used for skin beauty, cosmetics and treatments of various conditions such as pain and anxiety and continue to be highly marketed today despite their intrinsic risks.

The extraction of EOs is by no means simple. Common techniques for extraction include distillation and cold compression. Because of their hydrophobicity, the addition of a solvent is often required for both extraction and dilution of EOs. Solvents may include petroleum ether, methanol,  and ethanol  These solvents may be toxic pesticides such as methanol which has been associated with nausea, vomiting, headache, blurred vision, permanent blindness, seizures, coma, permanent damage to the nervous system or death. . Hence, there is no such a thing as “pure” essential oil.

Historically, EOs have been perceived as safe. This misconception is rooted from the fact that all herbs are considered safe because they are ‘natural’. This has led to an increase in use and misuse of EOs  With increased popularity of EOs for aromatherapy, there has been an expansion of EOs use in other products, even in EO products  advertised for their efficacy in treating various disorders including dermatologic conditions.  While the FDA can enforce guidelines to restrict how products are marketed, it is important to recognize that EOs are not FDA regulated.

It is therefore not surprising that increased accessibility of these products by the public has led to an increase in their use. In dermatology, EO induced Allergic contact dermatitis (ACD) is not new to clinicians but it is becoming increasingly more prevalent. In fact, fragrances, which also contain EOs as ingredients, have been designated as the 2007 allergen of the year, by the American Contact Dermatitis Society (ACDS).

EO-induced ACD is of clinical importance as standard patch testing may miss EO sensitizations. If there is high suspicion for an EO allergy, it is important to perform expanded patch testing to avoid false negative results. In the US, melaluca (tea tree) and ylang ylang are common allergenic oils that could be potentially missed if testing was limited to standard fragrance. 

Another common myth is that toxicity of EOs correlates with dose concentration. In reality, all EOs can be toxic at high concentrations but there are some types of EOs that are inherently toxic even at low doses, especially when taken orally . Camphor is a very toxic compound which can prove fatal for infants and children on ingestion even in very small doses. The strong aroma associated with camphor has attracted its use in many EOs, especially as a remedy for the common cold. Patients who ingested camphor can develop severe nausea, vomiting, lethargy, ataxia, and even seizures. Inhaling eucalyptus offers a soothing effect when suffering from a cold, however ingestion of eucalyptus oils can lead to seizures. Nutmeg is an EO which enhances food flavor; misusing it can lead to hallucinations and coma. Thus, even ‘safe’ EOs can be detrimental to patients if misused.  Even EOs advertised as non-toxic have the potential to be toxic to certain vulnerable individuals and age groups (babies, elderly) and/or if taken for a long period of time.  

In summary, although some EOs have been recognized to have beneficial properties, they have the potential to be extremely hazardous and dangerous to humans. It is vital for patients to appreciate the complexity of EOs and be aware of the fact that they are not as “pure” nor as free of risks as advertised.

The Empty Truths Behind “Hypoallergenic” Labeling

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Zirwas MJ. Attempting to Define “Hypoallergenic”. JAMA Dermatol. 2017;153(11):1093‐1094. doi:10.1001/jamadermatol.2017.3045

Liem O, Kessen K, de Groot H. Hypoallergene dieren behoren tot het rijk der fabeldieren [Hypoallergenic animals, fact or myth?]. Ned Tijdschr Geneeskd. 2019;164:D4298. Published 2019 Dec 31.

Reviewed by Jalal Maghfour and Dr. Alina Goldenberg

Hypoallergenic is a term that has been traditionally associated with “allergens/fragrance free”.  Often time, products labeled as hypoallergenic are expensive and are advertised as a safe alternative for individuals who are sensitized to certain allergens.  Additionally, the term has gradually gained popularity in describing certain domestic animals, such as cats and dogs, that in theory, will not cause an allergic reaction. In reality, the term “hypoallergenic” is a dynamic word; its definition continues to evolve and change. 

In this synopsis, we focused on articles that discuss what the new criteria of hypoallergenic term is  and we hope, through this synopsis, to dismantle common misconceptions about hypoallergenic products as well as domesticated animals with the goal to aid clinicians in counseling patients suffering from allergic conditions.

The most important question to ask is: Are there any products that are truly hypoallergenic? The simple answer is “No”.  There are no such products that are “non-allergenic”. Instead, certain allergenic compounds can still be used if they induce a skin reaction at a low frequency in the general population.

Recently, the North American Contact Dermatitis Group (NACDG) has decided that for a product to be considered hypoallergenic it should not contain any allergenic ingredients that have a frequency of positive patch test results of 1 % or greater. This data was derived from a comprehensive patch test database containing at least 1,000 patients. While this frequency was set arbitrarily, it has been partially followed in practice—allergens yielding a positive patch test at a frequency greater than 1% are often added to screening trays used in patch testing.

In parallel, there is an increasing belief that some breeds/types of cats and dogs are hypoallergenic. This is a common misconception, as these types of animals do not exist. Instead, sensitized individuals may experience a reduction in skin reaction episodes in the presence of animals that shed less fur. This is because the offending allergen— dander (dead flaky skin), is often adherent to the fur which is shed at a different frequency based on the type of animal.

Hence, when counseling patients, it is important to emphasize that there are no such things as hypoallergenic products and/or animals. If manufacturers adhere to the 2017 NACDG definition of “hypoallergenic” for their product labeling, these products will truly be less likely to cause a skin reaction and will promote patients’ safety.

Nickel Allergic Contact Dermatitis: Identification, Treatment, and Prevention

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Review and Synopsis by Jalal Maghfour, MD and Alina Goldenberg, MD of Original Peer-Reviewed Article:

Silverberg NB, Pelletier JL, Jacob SE, Schneider LC; SECTION ON DERMATOLOGY, SECTION ON ALLERGY AND IMMUNOLOGY. Nickel Allergic Contact Dermatitis: Identification, Treatment, and Prevention. Pediatrics. 2020;145(5):e20200628. doi:10.1542/peds.2020-0628

Nickel (Ni) remains one of the most common causes of allergic contact dermatitis (ACD), a type IV hypersensitivity reaction, since the publication of its first case in 1888 by Dr. George Henry Fox. This metal continues to be highly prevalent in every day goods within the US. Ni ACD is considered a public health issue and has been gaining international attention.

The impact of nickel on both adults and children has been increasingly reported in the literature. However, Ni ACD is primarily a disease of the young as it rarely affects elderly (> 60 years). In this synopsis, we provide a brief overview on an article written by Silverberg et al. in which the authors discussed epidemiology, clinical presentation, pathogenesis and management of Ni ACD among pediatric population.

With the discovery of Ni in the 18th century and advancement in the steel industry in early 19th century, Ni has become commonly utilized among manufacturers and is now considered the 5th most common metal in the world. Ni ACD may manifest as mild pruritus with ill-defined erythema to diffuse and pronounced redness with oozing and bullae. Classically, Ni ACD presents as an erythematous lichenified papule/plaque and matches the object touching the specific skin area. Any parts of the body can be affected by nickel.

Ni ACD has a multifactorial etiology with a combination of genetic and environmental factors. Contact with nickel is simply not enough for a reaction to occur. The following conditions must be met for both induction and elicitation phase to occur: 1) Contact with a metal containing corroded Ni, 2) degree of solubility of Ni (higher the solubility the higher ion leakage); 3) Ni ions being absorbed by the skin.

In case of a Ni ACD, the majority of diagnoses are clinical. However, when the cutaneous patterns are atypical, the diagnosis may be difficult in which cases patch testing can be performed. Patch testing is the criterion standard method to diagnose Ni ACD. While it is usually a localized reaction, the appearance of 3 large papules following Ni patch testing strongly suggests a systemic nickel hypersensitization.  

Ni ACD can be a diagnostic challenge in AD patients as the morphologic eruption may not match the triggering object. In addition, patients may also experience an exacerbation of their AD. In parallel, adults with psoriasis often experience flare of their disease during a Ni ACD episode. Although Ni ACD is primarily a type IV reaction, immediate hypersensitivity through IgE has been reported as a cause of Ni ACD.

For Ni ACD treatment, this review recommends the avoidance of the offending agent as the next best step in management, followed by the treatment of inflammation with the use of glucocorticoids (potency is based on the affected area). Finally, restoration of the skin barrier is essential. This can be performed with a generous application of emollients. 

As exemplified by Denmark and Finland, enacting a national policy to regulate the amount of Ni that a population is exposed to was proven efficacious in reducing the rate of Ni ACD and has increased awareness on the topic among adolescents. There is no such regulation within the US. Because Ni is primarily found in jewelry and ear piercings, it may be beneficial to regulate Ni found in other forms of jewelry, as well as children’s toys, metal protectors for phone which are now increasingly recognized to as a cause of Ni ACD.

Increased production and manufacturing regulations, specific diagnoses and focused avoidance strategies can make Ni ACD a preventable pediatric health issue.  As it was shown with European countries, the United States can benefit from limiting Ni exposure to its population.  Until then, individual awareness and knowledge of daily objects containing nickel should be encouraged as part of avoidance.

FDA data on the TRUE Test

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This article updated in Nov 2015 on the Thin-layer Rapid Use Epicutaneous (T.R.U.E.) test discusses Indications and Usage, Dosage and Administration, and Contraindications, Timing of the Reads, Interpretation Instructions — use in specific populations (pregnancy, nursing, pediatric) — detailed allergen composition and the ten clinical studies were conducted in North America and Europe evaluating sensitivity and specificity, and/or agreement with a reference allergen…

 

To read full article: http://www.fda.gov/downloads/BiologicsBloodVaccines/Allergenics/UCM294327.pdf

High concentrations of isothiazolinone and mislabeling – Belgium

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This article discusses the evaluation of MI in products in Belgium and the verification of accurate labeling and regulatory compliance.  They found that concentrations of MI may be “(too) high” and labelling may be incorrect.

“Aerts O1, Meert H2, Goossens A3, Janssens S2, Lambert J1, Apers S2.  Methylisothiazolinone in selected consumer products in Belgium: Adding fuel to the fire?  Contact Dermatitis. 2015 Sep;73(3):142-9. doi: 10.1111/cod.12449.

Methylisothiazolinone (MI) contact allergy is severely affecting consumers with allergic contact dermatitis, owing to its presence in cosmetics, household detergents, and water-based paints, in particular. Data on the true isothiazolinone concentrations in these products are scarce, and labelling may be incorrect.”
“OBJECTIVES:
To report on the MI concentrations in such products marketed in Belgium, in order to verify the accuracy of labelling (when applicable) and compliance with EU regulations.
MATERIALS AND METHODS:
Thirty cosmetics (18 leave-on and 12 rinse-off), eight detergents and four paints were analysed for MI by the use of high-performance liquid chromatography with ultraviolet detection.
RESULTS:
The analysed leave-on, and to a lesser extent the rinse-off, cosmetics, contained MI at concentrations far exceeding the permitted 100 ppm use concentration. Household detergents contained high concentrations of MI, and mislabelling occurred for both cosmetics and detergents. The (limited) data on paints are in line with the existing literature.
CONCLUSION:
Cosmetics and detergents may facilitate contact sensitization because of a (too) high MI concentration, and mislabelling may make its avoidance extremely difficult. Safer use concentrations and correct labelling should be ensured by adequate quality control.”

This is not an OPEN ACCESS article.  The article can be rented at: http://onlinelibrary.wiley.com/wol1/doi/10.1111/cod.12449/full

nickel workshop

Nickel Workshop

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On June 23, 2016, a historic event occurred – the first US Nickel Workshop.  Thought leaders from medicine, industry and regulation came together to discuss the issue of nickel dermatitis,  appropriate uses of nickel, and the integral role of nickel in society at the first North American Workshop on Nickel Dermatitis. This workshop was sponsored and coordinated by the Nickel Institute, who brought toxicologists and dermatologists together with conscientious companies representing various consumer product sectors. The group stressed the importance of nickel release, not nickel content in determining risk of becoming allergic to nickel and having a nickel dermatitis reaction if you are already allergic to nickel.

Removing nickel from our environment is not possible, because it is one of the most abundant metals on our planet and it has many beneficial uses where it cannot be reasonably substituted (e.g. stainless steel) . What is possible, though, is to use it in the safest ways possible. For example, nickel is safely used in several types of stainless steels. Nickel is also used as nickel-plated carbon fibers in the composite case of personal cell phones to keep our brains safe from the electromagnetic energy generated from by cell phone use. A top priority was discussed at the nickel workshop of removing high nickel-release materials from use in piercing posts (used in jewelry) by using appropriate low nickel-releasing materials (e.g. surgical stainless steel, high quality gold, etc.) since piercing directly introduces releasednickel to an open wound. This is especially important for children who, if sensitized, have a lifetime to deal with the consequences.

The Nickel Institute will be putting together a full report from the Nickel Workshop, which will be made available online on the Nickel Institute website at https://www.nickelinstitute.org  Dr. Jennifer Chen, MD, a dermatologist from Stanford University, presented the background of nickel allergy in the US at the Nickel Workshop in addition to developing an outreach education webinar on this topic available to the public https://www.dermatitisacademy.com/webinars/  The webinar discusses that EU regulations have decreased nickel allergy in ear pierced young women from 16.6% down to 6.9%. The estimated savings of $2 billion over the last 20 years is massive and that could translate into an even bigger savings with the US population.

At the Nickel Workshop, Dr. Sharon Jacob, MD, a dermatologist from Loma Linda presented the situation of nickel dermatitis in children in North America, noting that nickel allergy is found at an early age and is thought to be largely due to ear piercing in young girls.  She reported that an estimated 11% of the US general population is currently sensitized to nickel, which includes an estimated 8,133,603 children!  She also stated that a significant proportion of these could be prevented by utilizing safer metals in piercing.  Dr. Jacob ended her presentation at the Nickel Workshop with a slide that said:

‘You can’t tell an adult they can’t pierce and smoke… but you can protect a child.’

To learn more about nickel allergy and sensitization, please visit the Dermatitis Academy page dedicated to nickel https://www.dermatitisacademy.com/nickel-page/ which includes information on the low nickel diet, how to DMG test metal objects to screen for nickel release, a quiz on sources of nickel and a general population questionnaire on nickel sensitization.  https://emg.wufoo.com/forms/nickel-allergic-contact-dermatitis-survey/

 

 

Preservative allergy alert!

Update on isothiazolinone (preservative) contact dermatitis

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New! Off the Press today! An update on the impact of isothiazolinone (preservative) contact dermatitis allergy .

“Allergic contact dermatitis (ACD) is a socially and economically significant condition. ‘We are in the midst of an outbreak of allergy to a preservative [methylisothiazolinone] which we have not seen before in terms of scale in our lifetime…. I would ask the cosmetic industry not to wait for legislation but to…address the problem before the situation gets worse,” stated John McFadden, FRCP, consultant dermatologist at St. John’s Institution of Dermatology in London, in a 2013 article in The Telegraph. Because MCI was believed to be a more potent allergen than MI, MI was approved for use as an individual pre- servative in industrial products in 2000 and in cosmetics in 2005. Comparing pooled prevalence rates… In the 1980s, in response to the newly recognized isothiazolinone allergens, expert panels from the United States and European Union recommended more strict concentrations in cosmetic products. The Scientific Committee on Consumer Safety (SCCS) recommended to the Cosmetic Directive of the European Union to limit. ‘”

Read more: UPDATE ON ISOTHIAZOLINONES.   Isothiazolinones, including (methylisothiazolinone, methylchloroisothiazolinone, and benzisothiazolinone, are common synthetic biocides/preservatives found in many skin and hair products as well as industrial products.

By MICHAEL LIPP, DO, MISHA BERTOLINO, MA, ALINA GOLDENBERG, MD, MAS, AND SHARON E. JACOB, MD in The Dermatologist™.  Please click the ‘prevent’ button on Break the Isothiazolinone Cycle on the Dermatitis Academy Isothiazolinone allergen (hapten) page.

Goblin's Copper Nickel Policy

Time for Nickel Policy

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Goblin’s Copper –The Time For a Nickel-Directed US Health Policy is Here. In THE DERMATOLOGIST, Vol 23 – Issue 3 – March 2015, pg 18-21

By Sharon E. Jacob, MD, Alina Goldenberg, MAS, Nanette Silverberg, MD, Luz Fonacier, MD, Bruce Brod, MD, Richard Usatine, MD, Robert Sidbury, MD, MPH, James Young, DO, Anthony Fransway, MD, Jonathan Silverberg, MD, PhD, MPH, Albert Yan, MD, and Janice L. Pelletier, MD, FAAP

Review by Chandler Rundle, BS. MSI, Loma Linda University

For years, nickel sensitization has plagued individuals of all ages. Nickel allergy can present as a localized or diffuse reaction, leading the reaction to often be confused with other conditions such as atopic dermatitis. Cases of nickel allergy are increasing, but there is minimal legislation on nickel restriction. The Jacob et al. article reviews/highlights that:

*International initiatives that regulated the allowable amount of nickel release from items inserted in piercings limited to <0.2 μg/cm2/week has led to decreased sensitization rates and a cost savings of $2 billion US dollars over a twenty year period.*A significant percentage of the clinical cases are unpublished – hence underrepresented.
* Half of the subjects sensitized to nickel have never consulted a doctor because of their nickel dermatitis
*Rates of nickel dermatitis have risen significantly. While awareness of nickel dermatitis has heightened as a public health issue.
* United States legislation has yet to formulate regulation of nickel in products – as Europe did in the 1990’s.