Collection of Blogs related to information about contact dermatitis

It’s True – Metals in a Tattoo – Systemic Contact Dermatitis

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Yes, indeed metals can be implanted in a tattoo… and systemically activated reactions can occur in those tattoos related to those metals…

“We recommend assessment of permanent tattoos for inflammation in all patients undergoing patch testing, for additional diagnostic correlation.”  [ 2008 Sep-Oct;19(5):E33-4]

 

Article 1 (came out yesterday) :de Cuyper C1, Lodewick E2, Schreiver I3, Hesse B4, Seim C5,6, Castillo-Michel H4, Laux P3, Luch A3.   2017 Aug 9. doi: 10.1111/cod.12862. [Epub ahead of print]  Are metals involved in tattoo-related hypersensitivity reactions? A case report.

“BACKGROUND:  Allergic reactions to tattoos are not uncommon. However, identification of the culprit allergen(s) remains challenging.

OBJECTIVES: We present a patient with papulo-nodular infiltration of 20-year-old tattoos associated with systemic symptoms that disappeared within a week after surgical removal of metal osteosynthesis implants from his spine. We aimed to explore the causal relationship between the metal implants and the patient’s clinical presentation.

METHODS: Metal implants and a skin biopsy of a reactive tattoo were analysed for elemental contents by inductively coupled plasma mass spectrometry and synchrotron-based X-ray fluorescence (XRF) spectroscopy.

RESULTS: Nickel (Ni) and chromium (Cr) as well as high levels of titanium (Ti) and aluminium were detected in both the skin biopsy and the implants. XRF analyses identified Cr(III), with Cr(VI) being absent. Patch testing gave negative results for Ni and Cr. However, patch tests with an extract of the implants and metallic Ti on the tattooed skin evoked flare-up of the symptoms.

CONCLUSION: The patient’s hypersensitivity reaction and its spontaneous remission after removal of the implants indicate that Ti, possibly along with some of the other metals detected, could have played a major role in this particular case of tattoo-related allergy.”

 

Article 2: Cobalt tattoo reaction:

2017 Jun 1;15(3):221-222. eCollection 2017.  Chemical Tattoo Treatment Leading to Systemic Cobalt Hypersensitivity.  Zajdel NJ1, Smith WA2, Taintor AR3, Jacob SE4, Olasz EB5.

“An otherwise healthy 36-year-old Caucasian woman, without prior history of atopic dermatitis or eczema, presented to an outside dermatologist with a generalized, severely pruritic eruption involving the entire body except the face. One month previously, she had used a 50% trichloroacetic acid tattoo removal solution on a blue-colored tattoo on the medial aspect of the left ankle. The patient’s eruption persisted for 7 months, and after several attempts to slowly taper her prednisone dose, she presented to our institution. On physical examination, there was a 3-cm erythematous, lichenified plaque surrounding the tattoo (Figure). On the trunk and upper regions of the arms, there were scattered, 1- to 2-cm, nummular patches and plaques. Biopsy of a truncal lesion revealed spongiotic pustules with a mixed dermal infiltrate and scattered eosinophils, consistent with subacute spongiotic dermatitis.”

 

Article 3:  Systemic Dermatitis following surgery — presenting as tattoo reaction

2017 Jul 19;3(4):348-350. doi: 10.1016/j.jdcr.2017.05.003. eCollection 2017 Jul.  Systemic contact dermatitis to a surgical implant presenting as red decorative tattoo reaction.
Cobb HK1, Shinohara MM2, Huss JT3, Welch MP2, Gardner JM2.
“The patient reported that within 2 weeks of surgery, the red-containing areas of her tattoos, which were previously flat and uninflamed, became raised and pruritic.”…
Read this article
Article 4: SCD to chromate in a tattoo triggered by patch testing
2008 Sep-Oct;19(5):E33-4.Inflammation in green (chromium) tattoos during patch testing.  Jacob SE1, Castanedo-Tardan MP, Blyumin ML.

“We report three patients with permanent tattoos and chronic dermatitis. During patch testing, the patients’ dermatitis worsened, and the previously quiescent green-colored portions of the tattoos became inflamed. All three patients were patch-tested and had positive reactions to potassium dichromate 0.25% in petrolatum. Avoidance led to the resolution of both the dermatitis and the tattooinflammation. We recommend assessment of permanent tattoos for inflammation in all patients undergoing patch testing, for additional diagnostic correlation.”

Article 5: 1962
1962 Aug-Sep;74:288-94.Green tattoo reactions associated with cement dermatitis.
CAIRNS RJ, CALNAN CD.
And … one of those reads that just makes you think… Article 6:
2004 Aug 21-27;364(9435):730.  A red tattoo and a swordfish supper.
Tsuruta D1, Sowa J, Higashi N, Kobayashi H, Ishii M.
Read more here
“Tsuruta et al. report- ed a case of a 40-year-old Japanese man with a red tattoo who developed a whole-body rash after eating 250 g of raw swordfish and alfonsino.”
Researchers are investigating metal allergic dermatitis and the role of piercing in nickel allergy.  Please pass along this survey.

Fiddler’s Neck and Nickel

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Review of: Fiddler’s neck: Chin rest-associated irritant contact dermatitis and allergic contact dermatitis in a violin player

Original Article: Caero, Jennifer E & Cohen, Philip R. (2012). Fiddler’s neck: Chin rest-associated irritant contact dermatitis and allergic contact dermatitis in a violin player. Dermatology Online Journal, 18(9).

Reviewed by: Jacqueline Chen, BA. MSII

  • String players such as violinists and violists can develop dermatitis (inflammatory skin disease), colloquially called ‘Fiddler’s Neck, which may occur on the submandibular region (just below the jaw) or the supraclavicular (on the neck) region.
    • Submandibular Fiddler’s neck, or Fiddler’s neck type 1, refers to the irritation caused by mechanical frictional that occurs following prolonged contact with the chinrest.
      • Submandibular Fiddler’s neck is often described as a lichenified (thickened) plaque that may be darker than the surrounding skin.
      • Four main factors contribute to Fiddler’s neck Type I: pressure of the fiddle, friction, hygiene, and the instrument position.
      • A barrier cushion and adjustment to more horizontal positioning of the instrument has been recommended between the chinrest and submandibular neck to avoid fiddler’s neck type 1
    • Supraclavicular Fiddler’s neck, or Fiddler’s neck Type II occurs from contact allergy to the materials in the chinrest apparatus on the instrument.
      • Supraclavicular dermatitis usually presents as a pruritic (itchy) and erythematous (red) eczematous plaques.
      • Allergic contact dermatitis (the allergic skin response) to the chinrest is most often caused by nickel sulfate in the bracket that holds the chinrest to the instrument, but can also be caused by allergens in the composite woods.
      • The diagnosis of Fiddler’s neck Type 2 is often made based on the patient history and through observing the musician playing his/her instrument to evaluate the contact point of the rash with the instrument.
      • A patch test is the diagnostic test to confirm allergic contact dermatitis
      • Notably, sweat can dissolve nickel, contributing to its corrosion and increasing nickel absorption by skin.
      • To confirm nickel release, the dimethylglyoxime (DMG) test can be used
      • https://www.youtube.com/watch?v=dJFcHo5fDbY
      • Treatment of supraclavicular Fiddler’s neck should be focused on avoidance of the component in the chinrest containing the allergenic material.

 

To read the article by Caero and Cohen please click here.

If you suffer from an allergy to your musical instrument, and would like to participate in a nickel allergy awareness survey, please click here.

Nickel allergy – immunologic inflammatory pathways

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Review of: Nickel sulfate promotes IL-17A producing CD4+ T-cells by an IL-23 dependent mechanism regulated by TLR4 and Jak-STAT pathways

Original article: Bechara, R, Antonios, D, Azouri, H, Pallardy, M, Nickel sulfate promotes IL-17A producing CD4+ T-cells by an IL-23 dependent mechanism regulated by TLR4 and Jak-STAT pathways. The Journal of Investigative Dermatology. 2017 Jun 17.

Reviewed by: Jacqueline Chen, BA. MSI & Brittanya A. Limone, MS, BS. MSIV

  • Allergic contact dermatitis (ACD) is classically described as a Type IV hypersensitivity reaction, however, the distinctive characteristics of a nickel-induced allergic contact dermatitis (Ni-ACD) lead to immunologic mechanisms that not only encompass a Th1 response but involve additional inflammatory cells, cytokines, and pathways.
  • In Ni-ACD, dendritic cells (antigen presenting [accessory] cells) play a critical role. Dendritic cells bind the antigenic nickel absorbed in the skin and then present it to T-cells at local lymph nodes, coordinating T-cell differentiation through cytokine messengers.
    • The two most crucial cytokine signals include:
      • IL-12p70 which promotes a T-helper Cell 1 type (Th1) response
      • IL-23 which stimulates the development of T-helper Cell 17 type (Th17) cells
    • Notably, the presence of IL-17A produced by Th17 cells correlates with the clinical reaction in nickel allergic patients. An injection of anti-IL-17 neutralizing antibodies may limit the severity of the contact hypersensitivity.
    • The IL-23/IL-12p70 balance determines the primary immunologic mechanism of the hypersensitivity reaction.
      • Increases in the IL-23/IL12p70 balance lead to a greater Th1 cell polarization
      • Decreases in the IL-23/IL-12p70 ratio produce a stronger Th17 cell response.
    • Brechara et al identified 5 specific modulators of T-cell differentiation that are important in the development of Ni-ACD through alterations in the IL-23/IL-12p70 balance.
      • IFN-γ
        • Produced by Th1 cells.
        • Greatly increases the IL-23 levels produced by nickel sulfate (NiSO4)-treated dendritic cells.
        • The increase in the IL-23/IL-12p70 ratio favors Th17 cell development.
      • Jak-STAT pathway
        • Inhibition of the Jak-STAT pathway increases IL-23.
        • Alternatively, activation of the pathway will increase IL-12p40 and IL-12p70 levels and decrease the IL-23/IL-12p70 balance.
        • This decrease in the IL-23/IL-12p70 balance favors a Th1 cell response.
      • TLR4, p38MAPK and NFkB pathways
        • Activation of these pathways is essential for nickel-induced production of IL-23, IL-12p40 and IL-12p70.
        • Since both IL-23 and IL-12 cytokines are produced, the IL-23/IL-12p70 balance remains high.
      • In summary, Ni-ACD is a complex immunologic disease involving not only a cell-mediated Th1 response but also Th17 cell development with alterations in IFN- γ levels and TLR4, Jak-STAT, p38MAPK, and NF-kβ immunologic pathways.

Article: link to publishers site

Researchers are investigating the role of piercings and the development of nickel allergy – please consider to take the Loma Linda University Nickel Allergy Survey:

Nickel allergy survey

 

 

Patch Testing in Hand Eczema – Free Article!

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REVIEW of: The Efficacy of the Patch Test in Diagnosing Hand Eczema

Original article: Vigneshkarthik, N, Ganguly, S, and Kuruvila, S. Patch Test as a Diagnostic Tool in Hand Eczema. Journal of Clinical Diagnostic and Research, 2016; 10(11): WC04–WC07. India

Reviewed by Jacqueline Chen, BA. MSI and Brittanya Limone, MA. MSIII, Loma Linda University.

  • Hand eczema is a frequently encountered dermatologic problem that may be secondary to an allergic contact dermatitis (ACD). Patch testing is a diagnostic tool that can confirm an ACD etiology and determine the necessary allergens to avoid to prevent future exacerbations.
  • Vigneshkarthik, Ganguly, and Krurvila’s cross-sectional study analyzed patch test results to determine common allergens associated with ACD in patients with hand eczema. The study included 54 individuals, 27 men and women. The authors discovered that:
    • Of the patients with hand eczema 37% had positive patch test results to 25 different allergens, confirming that ACD is a common cause of hand eczema
    • Specific occupations were more susceptible including housewives, agriculturists, students and masons
  • Nickel was the most common allergen associated with hand eczema, particularly amongst patients with a vesicular hand eczema, or pompholyx, morphology.
    • In patients with nickel allergy, high levels of nickel in the diet have been associated with this more severe form of hand eczema.
  • Risk factors thought to be associated with the development of nickel hand eczema:
    • Ear piercings and adornment with nickel jewelry.
    • Chores in wet environments
    • Use of nickel-containing utensils
  • Detergents were another important association with nickel allergy
    • Over one-third of patients with regular detergent exposure had a positive patch test result.
      • 54% of these positive patch test results were due to nickel, either alone or in combination with cobalt sensitivity.
      • The association of nickel and cobalt allergies was determined to be due to co-exposure to the metals from a common source.

PubMed Link:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5198439/   Adobe PDF Icon

TSW

Facing topical steroid withdrawal TSW – health matters

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TSW – topical withdrawal syndrome

Facing up to withdrawal from topical steroids 

By Mary C. Smith, RN, MSN; Susan Nedorost, MD; and Brandie Tackett, MD

“Topical corticosteroids applied to the face to treat these symptoms can cause steroid rosacea and steroid addiction syndrome, resulting in new symptoms that perpetuate the topical steroid usage.”  “withdrawal … which is called steroid addiction syndrome.”

” The best time to prevent … is when topical corticosteroids are first prescribed.”

” Getting the red out”

” Uncovering steroid rosacea”

” Stopping the cycle”

” Patient teaching”

Call to Action: “Learn to recognize this condition”

Get article here

 

Triggers of ACD – allergens and the jewelry addict

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Discussion of Triggers of Allergic Contact Dermatitis in Accessories – the Jewelry addict

Original article: Nanette B. Silverberg. (2016). The “Jewelry Addict”: Allergic contact dermatitis from repetitive multiple children’s jewelry exposures. Pediatric Dermatology 33: e103-e105

Reviewed by Lauren A. Ivey, MS. MSI & Brittanya A. Limone, MA, BS. MSIII Loma Linda University

  • Nickel Allergic Contact Dermatitis (Ni-ACD) can be a distressing problem, especially for young girls with pierced ears and a love for costume jewelry.
  • Nickel is the most commonly confirmed contact allergen in both children and adults.
  • Confirmed Ni-ACD has increased 3 to 4-fold since 1986.
    • Common sources of nickel exposure in children include jewelry and adornments, electronics, and school chairs.
    • Girls are especially at risk to early nickel exposure through earrings and daily us of costume jewelry (aka “jewelry addict”)
    • Electronics, eg cell phones, laptops, and tablets have increased the frequency of nickel exposure.
  • Silverberg presents a case study of a 9-year-old girl “addicted to costume jewelry” who developed ACD after exposure to different metal- and rubber-containing accessories.
    • Confirmed sources of the allergen exposure included rubber bracelets, cheaper metal jewelry, lip balm case and belt buckles.
    • Physical examination: classic involvement of the antecubital fossa (crease of arms) consistent with a diagnosis of atopic dermatitis, and lichenified plaques on the fingertips and dorsal hands.
    • Notable plaques were seen on the lips and perioral region associated with application of lip balm kept in the metal case.
    • Patch testing revealed a 3+ reaction to nickel (papular variant), 2+ to gold thiosulfate, and 3+ to thiuram, all of which were deemed clinically relevant considering the child’s history with jewelry containing these allergens and her  presentation.
  • Parents and caregivers must remain cognizant of important allergens in jewelry.
  • Because virtually any type of jewelry can be a source of allergy, children who exhibit persistent dermatitis should be tested for suspected allergens based on history and exposure.

Contact Dermatitis Awareness Ribbon

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Announcing the Contact Dermatitis Awareness Ribbon:

On March 19, 2016 a Montessori Teacher and a Customer Service Representative, two mothers with children suffering with allergic contact dermatitis, joined together to start a patient-centered outreach group on Facebook called “Eczema, Contact Dermatitis and Patch Testing Alliance”. Currently, this 1,925 member focus group is providing educational resources to sufferers of allergic contact dermatitis worldwide.

As the eve of the anniversary of the group approached the lead administrator (Misha Bertolino, MA) raised the question, Why is there not a contact dermatitis awareness ribbon?

**Contact dermatitis costs a reported $1,529 million/year in medical costs!

**Contact dermatitis is the 8th most costly skin disease!

**Contact dermatitis is preventable!

 

The Contact Dermatitis Awareness Ribbon is indeed very much needed!

In a collaborative effort, the Eczema, Contact Dermatitis and Patch Test alliance along with artist Janna Vassantachart, MD, logistician Chandler Rundle, BS, practicing contact dermatitis specialists, and global advocates – the orchid (eczema) and teal (allergy) contact dermatitis awareness ribbon has become a reality.

This symbol can be worn to show support and solidarity for the millions of people who suffer from this disease.  In alignment with these symbols, our mission at the Dermatitis Academy is to educate the public, the medical providers, the manufacturers and the legislators on ACD, while cultivating a community of support for those impacted by this disease.

With early diagnosis, education, and intervention, we HOPE for a future where allergic contact dermatitis can be controlled by remission or prevention.

Please visit the Dermatitis Academy to learn more about allergic contact dermatitis, allergens, and patch testing and to download the Contact Dermatitis Awareness Ribbon.

Please share!

Free article on Suspender Nickel dermatitis – prevention is the key

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Review of: ‘ Suspender ’ Dermatitis and Nickel Sensitivity

Original article:  D. Calnan and G. C. Wells. (1956). Suspender Dermatitis and Nickel Sensitivity. British Medical Journal, 1(4978), p. 1265-1268.

Reviewed by Brittanya Limone, BS, MA, MSIII, Loma Linda University.

  • Historically, nickel allergy contact dermatitis was primarily associated with women working in industrial processes.
    • Calnan and Wells use a case of suspender dermatitis, one of the most common causes of nickel allergic contact dermatitis c. 1956, to highlight the prevalence of this condition amongst women regardless of their employment.
  • A dermatitis reaction is thought to occur after friction and sweat wear on nickel-containing products. These mediums gradually remove the nickel coatings and allow for nickel ion absorption across one’s skin.
    • In addition to suspenders, other everyday nickel-containing products that may induce an allergic contact dermatitis include watches, bra clasps, and earrings.
  • Typically, the first reaction site occurs in direct contact with the metal, also known as the primary site. This region appears as excoriated, superficial papules or a confluent patch.
    • Of note, pierced earrings were noted to cause earlobe dermatitis with crusts and exudates that might be mistaken for impetigo (infection).
  • Eruptions at sites distant to the metal’s direct contact are secondary sites. These occur in a symmetric fashion on the eyelids, sides of the neck, inner thighs, and elbow flexures.
    • Secondary reactions develop as papules or vesicles overlying an erythematous, edematous background with or without crusts and exudates.
  • A secondary flare-up is a more important clinical feature for diagnosis and treatment.
    • In terms of diagnosis, patients might not typically seek medical care until a secondary eruption. Therefore, recognition of these lesions, more commonly, leads to the diagnosis of nickel sensitivity.
    • However, conditions with secondary flare-up reactions are more difficult to treat. Patients with a primary lesion respond quickly to therapy, but once a secondary eruption occurs, clearing the condition is difficult and recurrences are more common.
  • Patch testing is used to confirm the diagnosis of nickel allergic contact dermatitis. However, waiting for the alleviation of an acute exacerbation is important as false positives from local reactions to patch testing may occur.

 

  • Prevention is key to this condition’s treatment and reduces recurrences.
    • The first step is the removal of all jewelry, metal clips or fasteners.
    • If nickel-containing products must be worn, then they should be covered with a protective coating of fabric, plastic, or enamel.
    • Alternatively, replacement products may be used such as items made of 100% plastic or nylon.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1979680/

Only MCI/MI caused remarkable changes… skin cells affected

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“only MCI/MI reduced NMF levels significantly… only MCI/MI caused remarkable changes at the microscopic level” to corneocytes (resident skin cells)…The altered corneocyte morphology suggests that skin barrier damage plays a role in the pathogenesis of MCI/MI contact allergy.”

IMPORTANT WORK!

Koppes SA1,2, Ljubojević Hadžavdić S3, Jakasa I4, Franceschi N5, Riethmüller C6, Jurakić Tončic R3, Marinovic B3, Raj N7, Rawlings AV7, Voegeli R8, Lane ME7, Haftek M9, Frings-Dresen MH1, Rustemeyer T2, Kezic S1.  Effect of allergens and irritants on levels of natural moisturizing factor and corneocyte morphology.  Contact Dermatitis. 2017 Mar 14. doi: 10.1111/cod.12770.

“Abstract
BACKGROUND:
The irritant sodium lauryl sulfate (SLS) is known to cause a decrease in the stratum corneum level of natural moisturizing factor (NMF), which in itself is associated with changes in corneocyte surface topography.
OBJECTIVE:
To explore this phenomenon in allergic contact dermatitis.

METHODS:
Patch testing was performed on patients with previously positive patch test reactions to potassium dichromate (Cr), nickel sulfate (Ni), methylchloroisothiazolinone (MCI)/methylisothiazolinone (MI), or p-phenylenediamine. Moreover, a control (pet.) patch and an irritant (SLS) patch were applied. After 3 days, the stratum corneum from tested sites was collected, and NMF levels and corneocyte morphology, expressed as the amount of circular nanosize objects, quantified according to the Dermal Texture Index (DTI), were determined.

RESULTS:
Among allergens, only MCI/MI reduced NMF levels significantly, as did SLS. Furthermore, only MCI/MI caused remarkable changes at the microscopic level; the corneocytes were hexagonal-shaped with pronounced cell borders and a smoother surface. The DTI was increased after SLS exposure but not after allergen exposure.

CONCLUSIONS:
MCI/MI significantly decreased NMF levels, similarly to SLS. The altered corneocyte morphology suggests that skin barrier damage plays a role in the pathogenesis of MCI/MI contact allergy.  DTI seems to differentiate reactions to SLS from those to the allergens tested, as SLS was the only agent that caused a DTI increase.”

https://www.ncbi.nlm.nih.gov/pubmed/28295421
© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

NEW- ALLERGEN MATTERS – ATOPICS as greater risk for… BOP… Lanolin

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Cocamidopropyl betaine, Amerchol L-101 {lanolin} and many of the Fragrances are only available for testing with comprehensive patch testing.  Propylene glycol and MI also ones that can be frequently missed, because they are not specifically tested.  P.E.A.S – pre-emptive [allergen] avoidance strategy highlights this top allergens and Simple and Free highlights products devoid of them…

“Lubbes S1, Rustemeyer T2, Sillevis Smitt JH1, Schuttelaar MA3, Middelkamp-Hup MA1.    Contact sensitization in Dutch children and adolescents with and without atopic dermatitis - a retrospective analysis.     Contact Dermatitis. 2016 Nov 11. doi: 10.1111/cod.12711.
BACKGROUND:
Allergic contact dermatitis is known to occur in children with and without atopic dermatitis, but more data are needed on contact sensitization profiles in these two groups.
OBJECTIVES:
To identify frequent allergens in children with and without atopic dermatitis suspected of having allergic contact dermatitis.

METHODS:
A retrospective analysis of children aged 0-17 years patch tested between 1996 and 2013 was performed.

RESULTS:
Of all 1012 children tested because of suspected contact dermatitis, 46% developed one or more positive reactions, the proportions for children with (n = 526) and without (n = 395) atopic dermatitis being 48% and 47%, respectively. Children with atopic dermatitis reacted more often to lanolin alcohols (30% pet., p = 0.030), Amerchol L-101 (p = 0.030), and fragrances [fragrance mix I (p = 0.048) and Myroxylon pereirae {BOP} (p = 0.005)].   Allergens outside the European baseline series that frequently gave positive reactions in these groups included cocamidopropyl betaine and Amerchol L-101. Reactivity to these allergens was significantly more frequently found in atopic dermatitis children.

CONCLUSION:
Sensitization prevalences in children with and without atopic dermatitis were similar, but children with atopic dermatitis reacted significantly more often to lanolin alcohols and fragrances. Testing with additional series besides the European baseline series may be necessary, as reactions to, for example, cocamidopropyl betaine and Amerchol L-101 may otherwise be missed.”

https://www.ncbi.nlm.nih.gov/pubmed/27861990