Collection of Blogs related to information about contact dermatitis

Late Delayed Reactions – 13%

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“Patch test readings are usually performed on day 2 (48 hours) and day 4 (96 hours). However, reports in the literature identify delayed allergy to metals, corticosteroids, antibiotics, some preservatives, acrylic and methacrylic monomers and p-phenylenediamine.”

 

This article discusses 203 patients that were patch tested to the British Society for Cutaneous Allergy standard series and twenty-six patients (12.8%) had new positive reactions on day 7 (168 hours), Including “mercury 0.5% (2/26); cobalt chloride 1% (2/26); colophony 20% (2/26); disperse blue mix 106/124 1% (2/26); preservatives (4/26) that included Methylchloroisothiazolinone/ methylisothiazolinone, sodium metabisulfite, and diazolidinyl urea; fragrances (7/26); and gentamycin sulfate 20% (1/26).” http://www.ncbi.nlm.nih.gov/pubmed/24030365

 

Late delayed reactions have been reported also in patch tested children in the US – “Twenty-five of the 38 children (66%) had a positive reaction at 48 hours; 32 children (84%) had a positive reaction at 72 hours (day 3); 19 children (50%) had a positive reaction at 168 to 216 hours (day 7-9). Of those 19, 16 (42%) had persistent reactions, while 5 children (13%) had new late delayed reactions. Among the new late delayed reactions, there were six allergens identified, four of which were considered of probable clinical relevance.”  (the four with probable relevance were: Formaldehyde and formaldehyde related chemicals:  Formaldehyde, Q15, Diazolidinyl urea, p-tert-butyl formaldehyde resin).  http://www.ncbi.nlm.nih.gov/pubmed/21208272

patch test

On patch testing and the T.R.U.E. test

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What is Patch Testing?  Patch testing is a method for diagnosing delayed type hypersensitivity.  Chemicals (haptens) are applied on the skin with wells adhered to an adhesive strip.  The wells may be hand-loaded (‘comprehensive’) patch testing or may be preloaded in gels (‘patch test kit’, e.g.: T.R.U.E. test).   They are then left in contact with the skin for up to 48h, then removed and checked.  They are then re-evaluated between 72-120h (sometimes later).  Some reactions can appear later and the patient should monitor their back for new reactions for up to 8 weeks.  If a new reaction presents, they should notify their provider.

What is the T.R.U.E. test?  The thin-layer rapid epicutaneous (T.R.U.E.) testT. is a commercially available patch test kit that is approved for use in adults in the US by the Food and Drug Administration.

What is it used for?  It is used to confirm the diagnosis of allergic contact dermatitis (ACD) – a delayed hypersensitivity reaction.

How effective is the test?  Data from the North American Contact Dermatitis Group (NACDG), a US-based research group of patch testers, suggest ” Using a conservative calculation (assuming that individual components of a mix would not have been detected with a mix and vice versa), the conservative hypothetical detection rate of T.R.U.E. TEST allergens would be 69.7%”.  Which means that theoretically ~70% of the reactions that the NACDG detected with their screening panel would have been also captured if the T.R.U.E. test were used.  We say ‘theoretically’  because they are different systems and can have inherent differences in detection rates (see below).  One limitation of patch testing (in general) is that it is a confirmatory test, so you can only detect what is tested for.  Testing the patients products (shin-guards, personal hygiene products, medicaments) is an important adjunct to the standard patch testing, and can provide vital information about additional potential allergens and their sources. http://www.ncbi.nlm.nih.gov/pubmed/25581671

How does patch system compare to comprehensive testing (methods)?  There are variations within the patch test systems:

Comprehensive testing – Comparative study of IQ-ultra and Finn Chambers: “Both patch tests had a significant agreement in detecting all of the allergens. An “almost perfect agreement” was noted for ethylenediamine dihydrochloride, quaternium-15, mercapto mix, black rubber mix, balsam of Peru, and nickel sulfate; “substantial agreement” for formaldehyde, bisphenol A epoxy resin, and 4-tert-butylphenol formaldehyde resin; and “moderate agreement” for potassium dichromate.” : http://www.ncbi.nlm.nih.gov/pubmed/22417991

T.R.U.E. test versus Comprehensive testing; “Discordant positive reactions were examined for clinical relevance. The Finn Chamber methodology was superior in detecting clinically relevant allergies to fragrance mix, balsam of Peru, and thiuram mix. T.R.U.E. Test performed somewhat better than the Finn Chamber in detecting relevant allergic reactions to nickel, neomycin, and methylchloroisothiazolinone/methylisothiazolinone. Neither T.R.U.E. Test nor Finn Chamber methodologies performed optimally in detecting relevant allergies to formaldehyde and carbamates. Practitioners limited to only the T.R.U.E. Test methodology need to be aware that relevant reactions to fragrances, rubber accelerators/pesticides (carbamates and thiurams), and formaldehyde may be missed with this system.” http://www.ncbi.nlm.nih.gov/pubmed/11712026

Methyisothiazolinone may be missed:  “The clinical manifestations of allergy to MCI/MI and MI are highly variable and diagnosis is often missed. In the standard patch test series of the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC), MCI/MI is tested at 100 ppm, but at this concentration, up to 50% of cases might go undetected. Furthermore, our data indicate that MCI/MI at 200 ppm would make it possible to diagnose more cases of contact allergy to MI. To improve the diagnosis of contact allergy to MCI/MI and MI, we believe that the test concentration of MCI/MI should be increased to 200 ppm in the GEIDAC standard series and that MI should be added in the GEIDAC standard series.”  http://www.ncbi.nlm.nih.gov/pubmed/24626102

Additional information: http://www.ncbi.nlm.nih.gov/pubmed/24117737

Fragrances can be volatile and should be loaded into the patch chamber as close in time to the application to the patient as possible “Within a couple of hours several fragrance allergens evaporate from test chambers to an extent that may affect the outcome of the patch test. Application to the test chambers should be performed as close to the patch test occasion as possible and storage in a refrigerator is recommended.”  : http://www.ncbi.nlm.nih.gov/pubmed/22803625

For more information on contact dermatitis and patch testing – please visit the Dermatitis Academy at https://www.dermatitisacademy.com

 

 

Formaldehyde exposure

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On Formaldehyde exposure …formaldehyde is an important irritant and allergen.  Irritants disrupt the skin and permit increased absorption of allergens…  “Formaldehyde is the simplest of the aldehydes (HCHO). It is a gas at room temperature. It is obtainable in crystalline form or as a liquid. … There are two major sources of formaldehyde: direct commercial manufacture and indirect production. Commercial formaldehyde is used mainly in the synthesis of disinfectants, cosmetics, deodorants, paper, dyes, photographic materials, textiles, inks, wood products, synthetic resins, preservatives, leather, fertilizers, and insecticides. Indirect production of formaldehyde may occur through the photochemical oxidation of airborne hydrocarbons from vehicle exhausts, the incomplete combustion of hydrocarbons in fuels, and other sources. Other sources in the atmosphere include cigarette smoking levels over 0.2 ppm have been observed and anaerobic decomposition of methane by microbes.”

…

“Studies to evaluate formaldehyde sensitivity have been done by several investigators over the past 80 years, starting in 1909. In the 1909 study, subjects developed stomach or intestinal pains, headaches, and itchy rashes on the chest and thigh after drinking milk that contained formaldehyde.”  Formaldehyde exposure has been studied for more than 80 years!!!

“The concentration of formaldehyde for inhalation provocation testing in our studies was <0.2 ppm. This is lower than the perceptible odor level of 1 ppm noted by NIOSH.”  Formaldehyde exposure needs to be further studied!

“In 1981, the Committee on Toxicology of the National Research Council estimated that as much as 10% of the total United States population may be hypersensitive to the irritant effects of formaldehyde.”  Formaldehyde exposure and the clinical effects from this need to be documented!

The above quotes are from the article from Pan et al.  for more information please read:

Yaqin Pan et al.  Formaldehyde Sensitivity  Clinical Ecology VI(3):79-84  http://www.aehf.com/articles/A44.htm

 

This week the Dermatitis Academy has led out a campaign for awareness on formaldehyde allergy.  Please visit our dedicated formaldehyde allergy page:https://www.dermatitisacademy.com/formaldehyde/

A day in the life of a patch tester – Glove Protection – Formaldehyde

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It’s so true not all gloves are created equally!  There’s thickness, pliability, and then there is materials!!!   Did you know that latex does NOT adequately protect against formaldehyde?  It is INADEQUATE.
Oh yes!  Have seen fresh young medical student sensitized in anatomy lab by using [and reusing 🙁 ] latex gloves… when instead they should have been doubling up on the nitrile!

 

Here’s a great link from Umass, Boston:

https://www.umb.edu/ehs/lab_safety/ch_em_plan/appd

Latex gloves are inadequate, fragile and ‘perform very poorly against Organic Solvents.

They are also INADEQUATE protection for:

Most Aldehydes, including Formaldehyde…

Nitrile, the blue-purple ones, on the other hand,  WILL withstand:

Alcohols

Inorganic Acids and Bases including Chromic Acid, and Most Organic Acids

Organosilanes

Organic Nitrates and Nitrites

Some Aldehydes, including Formaldehyde and Glutaraldehyde’

 

https://www.umb.edu/ehs/lab_safety/ch_em_plan/appd

Nonfat milk (casein) binds formaldehyde in the wash

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Formaldehyde most definitely can be a cause of reactions to clothing!

It can be adult and children’s clothing – pants, shirts, underwear and bras. In an interview on bra reactions Dr. Joel Dekoven said “…in fact most physicians don’t know that…” (4:11)

 

So what can be done?  Wash clothes at least twice before wearing.  Select 100% cotton (or single fiber – no blends), except no RAYON!

What else can be done?

Treat your wash with non-fat milk!

Back in 1974, Dr. Subbart describe a method for binding free formaldehyde that was released in the wash:
F. James Stubbart, MD  Nonfat Dry Milk Helps Prevent Formaldehyde Dermatitis.  August 1, 1974, Vol 110, No. 2

“Formaldehyde present in clothing and sheets can produce allergic reactions. Most frequently, it is an irritant, especially to dry skin and areas exposed to increased friction or perspiration.Casein is an innocuous compound that, when added to formaldehyde, produces insoluble compounds used to make items, such as buttons, billiard balls, and water-proof adhesives. A small handful of nonfat dry milk added to the laundry rinse water precipitates free formaldehyde, this results in reduction of the skin irritation. This process also makes clothing and sheets feel softer. In some fabrics, the formaldehyde continues to be released, and after a few days the rinsing must be repeated.Excessive quantities of harsh laundry detergents may cause the same problem of itching.”

Available at http://archderm.jamanetwork.com/article.aspx?articleid=534309

 

~1/4 cup of non-fat dry milk into the wash…

A day in the life of a patch tester – Teens and padded bras – Formaldehyde

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When you look into the eyes of a saddened 14 yo girl who’s dermatitis for the last 7 months has been so severe that we can’t see her nipples from her areola — your heart just breaks.  You just have to find the answer and we did – patch testing revealed PTBFR in the foam of her bra…
The question is – what do you do?  Cotton bras!!!  But the teen says to me – I need padding – My ‘Macgyver-work around” cotton nursing pads sewn into a cotton bra!  
Herro EM1, Friedlander SF, Jacob SE.Bra-associated allergic contact dermatitis: p-tert-butylphenol formaldehyde resin as the culprit.  Pediatr Dermatol. 2012 Jul-Aug;29(4):540-1. doi: 10.1111/j.1525-1470.2011.01533.x. Epub 2011 Oct 20.

“P-tert-butylphenol formaldehyde resin (PTBPFR) is recognized as a significant source of allergic contact dermatitis in adults and children in association with athletic gear, shoes, and neoprene. To our knowledge, this is the first case report of allergic contact dermatitis with PTBPFR associated with padded foam bras.”

Access the article here: http://www.ncbi.nlm.nih.gov/pubmed/22011272

“I can’t find a bra – my underwear make me itch!” – living with formaldehyde allergy

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At the final patch test reading visit, once a positive reaction has been found, clinical relevance to the current dermatitis must be determined… then safe alternatives found… a challenge for the formaldehyde allergic person is clothing (textiles)…

Back in 2008, Dr. Andrew Scheman (Director of the Contact Allergen Management Program for the ACDS) led out a partnership initiative to form a collaborative [namely the American Contact Alternatives Group -ACAG]  which would work to find and share safe alternatives with each other and our patients, resulting in this manuscript:

Scheman A1, Jacob S, Zirwas M, Warshaw E, Nedorost S, Katta R, Cook J, Castanedo-Tardan MP.  Contact Allergy: alternatives for the 2007 North American contact dermatitis group (NACDG) Standard Screening Tray.  Dis Mon. 2008 Jan-Feb;54(1-2):7-156.
http://www.ncbi.nlm.nih.gov/pubmed/18215657

Since then, the ACAG collaborative has continued to work together and share with each other resources we find…

Here is a resource from CottoniqueTM:

“Each country has its own manufacturing standards for acceptable levels for formaldehyde resins. A low indicator of formaldehyde releasing resin would be 75 ppm which is the Japanese standard, the US standard is somewhere near 300ppm, quite a difference.

Fabrics safe to wear: 100% silk, 100% linen (if it wrinkles easy), 100% polyester, 100% acrylic, 100% nylon, spandex, flannel (soft), wool (may cause irritation) and denim.

Do not wear these fabrics: Permanent press, wrinkle resistant, color-fast, stain-resistant, blends (including rayon, polyester-cotton), corduroy or shrink-proof wool.

It is suggested that you read the labels in your existing clothing and separate them in your closet so you will know what’s safe to wear. Always opt for loose fitting clothing since friction and perspiration can cause the condition to flare. Read the labels in any new clothing before you purchase. Clothes made in Japan are the safest and companies that sell clothes in Japan also have to meet the Japanese standard.

Companies that meet the Japanese standard: GAP, Old Navy, Banana Republic, Liz Claiborne, Eddie Bauer, Cuddle Duds and Levi Strauss. There may be others but these were on the list from the American Contact Dermatitis Society.”

Blog from Cottonique [https://www.cottonique.com/blogs/blog/2424702-the-contact-dermatitis-and-clothing-connection]  https://www.cottonique.com

 

The Dermatitis AcademyTM has no financial or relevant relationship with CottoniqueTM, nor certifies their wares.