Collection of Blogs related to information about contact dermatitis

Simple & Free

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Simple & Free

By Hannah Hill, MD and Sharon E. Jacob, MD

It is time to be Simple & Free!  Pediatric allergic contact dermatitis (ACD) has been increasingly recognized in the United States over the last decade.  Reported rates of positive patch tests in children referred for suspected ACD range between 27% and 95.6%. Many young children are becoming sensitized to contact allergens found in personal hygiene products such as cleansers, moisturizers, sunscreens and topical medications like steroids and antibiotic ointments.  Dr. Jacob and her team have been promoting pre-emptive avoidance strategy (P.E.A.S.) since 2005, especially in patients with widespread dermatitis, and seeing a remarkable impact.  This led to the team developing the Simple & Free guideline, making P.E.A.S publicly available, with the goal of reducing skin rashes (dermatitis) associated with the top sensitizing allergens and potentially a decrease in sensitization.

With the goal of identifying the top allergens responsible for a significant portion of pediatric ACD caused by personal hygiene products, Hill et al. reviewed five recent pediatric patch test studies. The top ten allergens identified by this meta-analysis of the US pediatric patch test were neomycin, balsam of Peru (a screening substance for  fragrance allergy), fragrance mix, lanolin, cocamidopropylbetaine, formaldehyde, corticosteroids, methylchlorisothiazolinone (MCI)/methylisothiazolinone (MI), propylene glycol, and benzalkonium chloride. Upon review of the included studies it was also estimated that between one quarter and one third of children suffering from ACD could potentially benefit from a “pre-emptive avoidance strategy” (P.E.A.S.) of the stated top 10 allergens!  Dermatitis Academy then created the Simple & Free guideline to highlight the products devoid of the top 10 sensitizers.  Given that benzalkonium chloride (BAC) is a very rare allergen and well known irritant, the high reporting from one study in the meta-analysis likely represents irritant reactions being read as allergens.  For this reason BAC was replaced by para-phenylenediamine, a Consumer Patient Safety Commission (CPSC) designated ‘Strong Sensitizer’, in Dermatitis Academy’s top 10 sensitizers to be pre-emptively avoided.

http://www.ncbi.nlm.nih.gov/pubmed/22828255

http://www.ncbi.nlm.nih.gov/pubmed/18503686

By utilizing resources that identify consumer products for the presence, or lack of, specific contact allergens, consumers can use the pre-emptive avoidance strategy to select Simple & Free formulations and potentially prevent the development of, or remit ACD. Patients most likely to benefit from these efforts include those with eczema, sensitive skin, known allergy, or family history of inflammatory skin diseases.  This article briefly shows examples of products devoid of the top allergens, but consumers are encouraged to utilize Dermatitis Academy’s Simple & Free guideline, which utilizes the pre-emptive avoidance strategy P.E.A.S. to highlight products that are both Simple in their formulation and Free of the top 10 P.E.A.S. identified sensitizing allergens.

Article:Hill H, Goldenberg A, Golkar L, Beck K, Williams J, and Jacob SE. Pre-Emptive Avoidance Strategy (P.E.A.S.) – addressing allergic contact dermatitis in pediatric populations. Expert Review of Clinical Immunology.   2016 Jan  http://www.ncbi.nlm.nih.gov/pubmed/?term=P.E.A.S.

Aerosolized MI

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Aerosolized MI

Methylisothiazolinone (MI) is a preservative causing “an outbreak of allergy … 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 get on and address the problem before the situation gets worse,” Dr. John McFadden, dermatologist at St. John’s Institution of Dermatology in London, 2013.  Duffin, C., Warning over ‘epidemic’ of skin allergies from chemical in cosmetics and household products, in The Telegraph.  It is not just a preservative in personal hygiene products, it is also in cleaning supplies, air fresheners and household paint.  Notably, reactions can occur through airborne exposures through aerosolized MI.

 

Discussion by Phillip Grigsby, BA. MS3 and Sharon Jacob, MD,  Loma Linda University School of Medicine and Department of Dermatology

Aerts et al. describe a case of a 4 year-old girl who was believed to have been sensitized by skin exposure to methylisothiazolinone (MI) that was contained in Scottex Fresh® moist toilet paper (Kimberly Clark).1 The child developed a papular eruption (dermatitis) over an erythematous base at the site of the wipe exposure that eventually subsided after application of topical steroids and cessation of exposure to the wipes. Six months later, she had a similar, papular dermatitis involving her face, including nasolabial folds and eyelids, which was morphologically similar to atopic dermatitis in an airborne (exposed area) distribution. It was resistant to more potent topical corticosteroids, and continued to wax and wane for another 4 weeks. The child was epicutaneously patch tested and found to be contact sensitized (immune system recognized) to 25 parts per million (ppm) of MI (well below the levels in both the wipes and paint). In review of exposures, it was noted that her parents painted her room with water-based paint. Analysis showed that the paint contained MI at 53 ppm. Aerosolized MI in the paint was determined to be contributory to the development of the new dermatitis in this MI sensitized child.

http://www.ncbi.nlm.nih.gov/pubmed/23510347

 

MI was originally formulated as Kathon®, a mixture of methylchloroisothiazolinone (MCI) and MI.  It has since been discontinued in the European Union due to high rates of allergic contact dermatitis.2 MI currently is allowed allowed in select products (leave on, rinse off) to 100 ppm. A review of the literature found 21 cases of aerosol-induced (aerosolized MI) dermatitis to MI.3-7 Aerts et al. point out the first child to be confirmed to have this reaction. Of note, a similar case has since been reported where a three year-old girl was sensitized by MI-containing wipes, and later developed an airborne spread allergic contact dermatitis after paint exposure.6 Notably, the mimickry to atopic dermatitis (eczema) increases the risk that this child could have gone mis- or undiagnosed. Patch testing was vital in correctly making her diagnosis of allergic contact dermatitis, with systemic (airborne) activation. It is important to note that MI as a stand alone substrate is not included on the commercially available patch test screening kit. Testing with the MCI-MI combination substrate can miss up to 40% MI reactions, likely because the low concentrations of MI in the tests.8

 

References

  1. Aerts O, Cattaert N, Lambert J, Goossens A. Airborne and systemic dermatitis, mimicking atopic dermatitis, caused by methylisothiazolinone in a young child. Contact Dermatitis. 2013;68(4):250-251. http://www.ncbi.nlm.nih.gov/pubmed/23510347.
  2. Aerts O, Goossens A, Giordano-Labadie F. Contact allergy caused by methylisothiazolinone: the Belgian-French experience. Eur J Dermatol. 2015;25(3):228-233. http://www.ncbi.nlm.nih.gov/pubmed/26412037.
  3. Bohn S, Niederer M, Brehm K, Bircher AJ. Airborne contact dermatitis from methylchloroisothiazolinone in wall paint. Abolition of symptoms by chemical allergen inactivation. Contact Dermatitis. 2000;42(4):196-201. http://www.ncbi.nlm.nih.gov/pubmed/10750849
  4. Lundov MD, Mosbech H, Thyssen JP, Menne T, Zachariae C. Two cases of airborne allergic contact dermatitis caused by methylisothiazolinone in paint. Contact Dermatitis. 2011;65(3):176-179. http://www.ncbi.nlm.nih.gov/pubmed/21827510
  5. Vanneste L, Persson L, Zimerson E, Bruze M, Luyckx R, Goossens A. Allergic contact dermatitis caused by methylisothiazolinone from different sources, including ‘mislabelled’ household wet wipes. Contact Dermatitis. 2013;69(5):311-312. http://www.ncbi.nlm.nih.gov/pubmed/24117741
  6. Madsen JT, Andersen KE. Airborne allergic contact dermatitis caused by methylisothiazolinone in a child sensitized from wet wipes. Contact Dermatitis. 2014;70(3):183-184. http://www.ncbi.nlm.nih.gov/pubmed/24588371
  7. Jensen JM, Harde V, Brasch J. Airborne contact dermatitis to methylchloroisothiazolinone/methylisothiazolinone in a boy. Contact Dermatitis. 2006;55(5):311. http://www.ncbi.nlm.nih.gov/pubmed/17026706
  8. Castanedo-Tardana MP, Zug KA. Methylisothiazolinone. Dermatitis. 2013;24(1):2-6. http://www.ncbi.nlm.nih.gov/pubmed/23340392.

 

Additional articles that may be of interest (Aerosolized MI):

Airborne exposure to preservative methylisothiazolinone causes severe allergic reactions.

http://www.ncbi.nlm.nih.gov/pubmed/23212711

Generalized allergic contact dermatitis caused by methylisothiazolinone in a spray tan.

http://www.ncbi.nlm.nih.gov/pubmed/26098619

Five cases of severe chronic dermatitis caused by isothiazolinones.

http://www.ncbi.nlm.nih.gov/pubmed/23782361

 

methylisothiazolinone scrutiny

methylisothiazolinone scrutiny

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Methylisothiazolinone scrutiny is very much needed.  This preservative is sensitizing a significant number of adults and children worldwide.  It is found in personal products, household cleaners, household paint, and air fresheners.  Reactions to it may look like atopic dermatitis!

“Recalcitrant dermatitis, such as that of the hands, face, or genitals, may be due to allergic contact dermatitis (ACD) from ingredients in seemingly innocuous personal care products. Rising rates of allergy have been noted due to the preservative methylisothiazolinone (MI). This preservative is commonly found in skin and hair care products, especially wipes. This study evaluated the use of MI in products specifically marketed for babies and children and examined the associated marketing terms of such products. Ingredients of skin care products specifically marketed for babies and children were surveyed at two major retailers. Of 152 products surveyed, 30 products contained MI. Categories of products surveyed included facial or body wipes, antibacterial hand wipes, hair products, soaps, bubble baths, moisturizers, and sunscreens. Facial or body wipes and hair products were the categories with the greatest number of MI-containing products. MI-containing products were manufactured by a number of popular brands. Of note, products marketed as “gentle,” “sensitive,” “organic,” or “hypoallergenic” often contained MI, thus emphasizing the importance of consumer scrutiny of product choices. These findings reinforce the importance of educating parents and providing consumer decision-making advice regarding common skin care products, in order to help prevent ACD in children.” Learn more by clicking here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4197884/.

It is time for methylisothiazolinone scrutiny – there is an epidemic!  The Dermatitis Academy [www.dermatitisacademy.com] is tracking this epidemic and reporting new cases of methylisothiazolinone and new sources!!!  It is important that consumers continue to let the Food and Drug Administration [FDA] know that they are known to be allergic to methylisothiazolinone and which product they have reacted to.  Click here for information on FDA reporting: https://www.dermatitisacademy.com/methylisothiazolinone-page/

 

 

Nickel Summit Webinar

Nickel Contact Dermatitis Summit Webinar

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Nickel Contact Dermatitis Summit

For 53 years, nickel has been unparalleled as the most common allergen documented in patch-tested patients of all ages worldwide, which we call attention to as the Nickel Contact Dermatitis Summit approaches.  And yet, nickel sensitivity is a much wider problem than the documentation suggests, as Peltonen alarmingly and poignantly pointed out over 30 years ago: “half of the subjects sensitized to nickel have never consulted a doctor because of their nickel dermatitis; still fewer have visited a dermatologist”.    In the US we are in the midst of a prospering hidden nickel epidemic akin to that seen in Europe prior to nickel regulation legislation.  There are millions of adults and children sensitized each year – the rates are UNACCEPTABLE, because this is a PREVENTABLE cause of allergic contact dermatitis.  The Nickel Summit webinar by Dr. Jennifer Chen discusses the impact of nickel allergy in the US and the lack of regulation.

 

Article Synopsis

Below is a summary of an article speaking more to this topic.

Synopsis by Janna Vassantachart, MD Loma Linda University School of Medicine

Article: Goldenberg A, Vassantachart J, Lin EJ, Lampel HP, Jacob SE. Nickel Allergy in US Adults-A 53-Year Review of Indexed Cases. Dermatitis. 2015 Jul 14.

For 53 years, nickel has been unparalleled as the most common allergen documented in patch-tested US patients of all ages. In 1994, the European Union (EU) decreased rates of sensitization by enacting a Nickel Directive to regulate nickel release to no more than 0.5 µg/cm2/week. No such directive currently exists in the USA.

This study conducted a literature review of peer-reviewed adult nickel dermatitis cases published within the United States to identify trends over the past decades, sources of nickel sensitization, and regional variations.  It highlights the problem we are encountering at the top of the nickel contact dermatitis summit.   The results of the study demonstrated:

  • Between 1962 and 2015, there were 74 articles published reporting 18,251 cases of nickel sensitivity in US adults.
  • Over the past decades, the frequency of published articles on nickel sensitivity has continuously increased with a significant correlation (r = 0.798, P = 0.057). Compared to only one article published between 1960 and 1970, in the last 5 years, 30 articles have been published.
  • Five articles reported occupational exposures such as a stethoscope, chalk, and a military-issued lanyard chain from an identification neck tag (aka ‘‘dog tag’’). The most commonly reported nonoccupational sources were Essure contraceptive microinserts and Amplatzer septal occluders for atrial septal defects.
  • Geographically, 27 US states have had at least 1 reported case of adult nickel dermatitis.

Most nickel dermatitis cases seen clinically are neither patch-tested nor captured in the literature, allowing for a prospering hidden nickel epidemic towards the nickel summit. However, this study reveals that even the literature has seen a significant increase in published cases over the past decades. Rising rates of US nickel ACD highlight the need for medical professionals, legislators, and manufacturers to advocate for an EU-like Nickel Directive to regulate the release of free nickel.

 

 

The Dermatitis Academy Story

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It was 2004, Europe had instituted the European Union Nickel Directive limiting the allowable release of nickel from items that were in direct and prolonged contact with the skin and the sensitization (allergy) rates to nickel were plummeting.  I became aware of this great need in the United States and decided to pursue training at NYU with Dr. David Cohen in contact dermatitis.  That same year, at the University of Miami, we conceived the business model for an institute for contact dermatitis that would serve the growing needs of patients with contact dermatitis by offering the highest tier of comprehensive patch testing, serve the needs of trainees who could come to the center to learn in partnership with excellent patient care, and provide the most up-to-date evidence-based resources for education.  This marked the inception of the Dermatitis Academy.

Over the next three years, we grew the contact dermatitis practice at the University of Miami serving contact dermatitis needs throughout South Florida with referrals from Mexico, central and south America.  We trained dermatology residents and began a training program for Fellows and Affiliate Providers and laid the foundation for informational and interactive educational resources.

During this time I became actively (passionately) involved in a campaign for safer regulation of nickel in the US.    In 2008, as a member of the Public Relations Committee of the American Contact Dermatitis Society, we presented a resolution to the American Academy of Dermatology (AAD) to issue a health advisory and document a need for an EU-like nickel directive in the United States. In response, the AAD developed a Nickel Workgroup, which formalized the resolution and ultimately the Council on Government Affairs and Health Policy and Practice approved and presented to the American Medical Association House of Delegates (AMAHOD). In June 2011, the AMA-HOD adopted the nickel resolution and sent a letter to the Consumer Patient Safety Commission (CPSC) regarding nickel:

“The AMA urges the CPSC to protect the public health by issuing safety standards that would limit the amount of nickel in consumer products with prolonged skin contact.”  The Deputy Executive Director for Safety Operations at the CPSC responded, “The issue of nickel sensitization and consumer products is one that the CPSC and its staff have been aware of since the agency’s inception” (CPSC inception was in 1972)!

In February 2015, we formally launched the Dermatitis Academy in partnership with the Nickel Allergy Alliance to track the pediatric and adult cases of nickel in the US and bring awareness to this silent epidemic.  We redrafted a nickel resolution and submitted it to the American Contact Dermatitis Society’s (ACDS) Health Policy Committee.  In partnership with this committee, the American Academy of Pediatrics, the American Academy of Allergy Asthma and Immunology and the American College of Asthma Allergy and Immunology and the National Eczema Association the resolution was finalized and submitted to the AAD, which approved the resolution and formed a nickel workgroup to study the issue and develop a position statement.  In August 2015, the AAD publicly issued a nickel position statement.

Twelve years later, I am still actively engaged in this public health campaign.  In March 2016, the Dermatitis Academy launched the free website to expanded the outreach, to provide educational resources on the most prevalent allergens identified through evidence-based meta-analysis of the literature, webinars, and the Simple and Free™ guideline.

This month (May 2016), just two months since the launch of the public website, we have had over 31,000 visits to our site… We hope you find the Dermatitis Academy a useful education tool… please share.

 

Test Your BOP Savvy – Which of these items might contain BOP?

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Read more

Management of Nickel Allergy

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Nickel allergy affects individuals of all ages and proves to be the number one sensitizing agent worldwide. Correct diagnosis is vital, as the localized or diffuse reactions that are associated with nickel allergic contact dermatitis may be confused with other conditions – resulting in delay of the appropriate care. Due to the increasing number of cases, there is an outstanding necessity to understand the source of sensitization, diagnosis, preventative/therapeutic strategies, and prognosis of nickel article.

This review by Chandler Rundle, BS. MSI, Loma Linda University of Management of contact dermatitis due to nickel allergy: an update. Fernanda Torres, Maria das Graças, Mota Melo, Antonella Tosti.  In CLINICAL, COSMETIC AND INVESTIGATIONAL DERMATOLOGY, Vol 38 – 2009, pg 39-48 highlights:

Introduction

  • Worldwide, the prevalence of nickel allergic contact dermatitis is about 8.6%. While prevalence in young women is approximately 17%
  • A genetic predisposition may cause a higher prevalence of nickel allergy.
  • In the United States, as much as 16.2% of the US population has had a reaction to nickel.

Source of Sensitization

  • Sensitization can occur from exogenous (skin contact) or endogenous (oral, inhalation) exposure with products containing nickel.
  • Nickel allergy may be associated with other metal allergies, such as chromium and cobalt and allergy to one metal may increase the reactivity to another metal.

Diagnosis

  • Clinical features of nickel allergic contact dermatitis include localized primary eruptions, characterized by recurrent lesions at sites of direct contact with nickel.
  • Sensitized individuals may experiences systemic allergic contact dermatitis (reactions at distant sites or from an inhalational, ingestion, implantation dose). Reactions occur in a dose-response relationship
  • While nickel contact allergy is diagnosed with patch testing, the test only measures sensitization; not clinical disease
  • Positive patch tests to nickel are seen in 10-30% of women, 2-8% of males, 15.9% of children, and 13.7% of individuals older than 65.
  • Dimethylgloxime (DMG) spot-test is a method used to identify items that contain nickel. Items with a positive result may induce dermatitis.
  • Other methods, such as oral provocation (stimulation), lymphocyte proliferation, and the prick test, can also be used to detect nickel allergic contact dermatitis, but are not routinely suggested.

Preventative Strategies

  • The most sure way to prevent recurrence of dermatitis is to avoid skin contact with items that release nickel.
  • Additional measures, such as use of antiperspirants or decrease in smoking, can decrease the recurrence of allergic contact dermatitis.

Therapeutic Strategies

  • Nickel allergic contact dermatitis may have varying clinical manifestations. Thus, it is important to recognize that these manifestations may require different forms of therapy.
  • Steroids, calcineurin inhibitors, psoralen plus UV-A, disulfiram, binding agents/barrier creams, and posttibly a low nickel diet serve as therapies in differing capacities.

Occupational Allergy

  • Occupational allergy often presents as hand eczema, which can lead to the inability to work.
  • In addition to preventative and therapeutic strategies needed to prevent recurrence, conditions in the workplace environment must also be improved.

Prognosis

  • Nickel sensitization is a lifelong condition, but with early diagnosis and proper management (through avoidance), prognosis of this condition is often good and remission sustained.
  • Factors that may worsen the prognosis include, ‘continuous nickel exposure, involvement of the hands, secondary bacterial infection, history of atopic dermatitis, and multiple contact allergies.’ [Multiple contact allergies – polysensitization]
Photo of positive DMG test

Electronics cause nickel rash (iPad)

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Nickel sensitization (and the clinical manifestation of nickel allergic contact dermatitis) is an issue that affects individuals of all ages. Nickel allergic contact dermatitis may present as a diffuse, or localized reaction, often leading the allergy to be confused with other conditions such as atopic dermatitis. While cases of nickel allergy are increasing, the cause of sensitization may not always be clear. Allergens must be identified, and actions must be taken to prevent contact.

This review by Chandler Rundle, BS. MSI, Loma Linda University of  iPad – Increasing Nickel Exposure in Children.  Sharon E. Jacob, MD and Shehla Admani, MD  In PEDIATRICS, Vol 134 – Issue 2 – 2014 highlights that:

*Flares of atopic dermatitis may be associated with increased contact with items containing nickel.

*Electronic devices, including the iPad, are a potential source of nickel sensitization in children.

*To prevent sensitization from electronics (and flares of allergic contact dermatitis), measures should be taken to minimize contact, such as including a case or duct tape as a barrier.

*With the increasing prevalence of nickel allergy among the pediatric population, identifying relevant allergens must become a priority in order to prevent AD flares.

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.