Blogs related to nickel allergic contact dermatitis

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.

 

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.

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.

nickel allergy cartoon

Detection of Nickel Sensitization – Article Review

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Original article: HERE

Rietschel RL, Fowler JF, Warshaw EM, Belsito D, DeLeo VA, Maibach HI, Marks JG, Mathias CG, Pratt M, Sasseville D, Storrs FJ, Taylor JS, Zug KA. Detection of Nickel Sensitivity has Increased in North American Patch-test Patients. Dermatitis. 2008 Jan-Feb;19(1):16-9.

Review by Daniel No, BA. MSIII Loma Linda University School of Medicine

The prevalence of nickel contact allergy has steadily increased in men and women since the 1990s. The authors, Rietschel et al., enrolled 25,626 patients during the years 1992 to 2004 to undergo patch testing to detect nickel sensitivity. The data from this study demonstrated:

  • The nickel sensitization rate has steady increased from 14.5% in 1992 to 18.8% in 2004. The upward trend further emphasizes the importance of public awareness and education of nickel contact dermatitis. significant impact this allergen has on the North American population.
  • Females from 2001 to 2004 were 1.1 to 1.2 times more likely to be sensitive to nickel in comparison to females tested from 1992 to 2000. Similar results were found in the male population, however, the findings were not statistically significant.
  • Younger males (< 19 years old) were 2.33 times more likely to be sensitive to nickel than their older counterparts. Similarly, younger females were found to be 1.51 times more likely to be nickel sensitive.
  • The patch test is essential in identifying specific allergens in allergic contact dermatitis. Patches containing 2.5% nickel sulfate were applied and left in place for 2 days and subsequently interpreted when removed. A follow-up interpretation was conducted one to five days later.

Nickel May be Released from Laptop Computers – Article Review

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Original article: HERE

Jensen P, Jellesen MS, Møller P, Johansen JD, Liden C, Menne T, Thyssen J P, Nickel May be Released from Laptop Computers

Review by Jin Yang, MSI, Loma Linda University School of Medicine

Prolonged and repeated skin contact to items that release nickel result in consumer nickel sensitization and subsequent nickel-allergic contact dermatitis. Laptops are widely used and often for a prolonged time. Jensen et al found nickel release from Apple laptops, raising concern for nickel sensitization and allergic dermatitis from laptop computer devices. The Jenseni et al article highlights:

  • Nickel release was tested by dimethylglyoxime (DMG) from 20 randomly selected Apple laptops in Denmark.
  • Nickel was detected from the top and the bottom of 1/3 of the investigated devices and from all the computer mice.
  • No nickel was released from the hand resting area.
  • In general electronic devices provide a substantial exposure to nickel contact for the general population.

iJensen P., Jellesen M.S., Møller P., Johansen J.D., Liden C., Menne T., Thyssen J. P., Nickel may be Released from Laptop Computers

 

 

Low-nickel diet scoring system for systemic nickel allergy – Review

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Original article: HERE

Mislankar M, BS, Zirwas MJ, MD. Low-nickel diet scoring system for systemic nickel allergy. Dermatitis. 2013;24:190-5.

Review by Annelise Rasmussen, BS. MSI, Loma Linda University

In patients with severe recalcitrant allergic contact dermatitis a low nickel diet may improve skin symptoms. Symptom severity directly correlates to the amount of ingested. Therefore, a low nickel diet can reduce cutaneous manifestations of nickel allergy.

Mislanker and Zirwas propose a point-based diet centered upon the nickel content of various foods in order to help patients lower nickel intake and therefore reduce symptoms. Guidelines included in the proposed diet include[1]:

  • Be persistent, the low nickel diet may take up to 2 months before improvement.
  • Limit dietary intake of nickel to less than 150 μg/day. This limit may be lowered in cases of children or more sensitive patients to 100 μg/day.
  • One point is assigned for every 10 μg of nickel consumed, giving a daily limit of 15 points.
  • In general high nickel foods such as all beans, chocolate, soy, nuts, oatmeal, and granola should be avoided.
  • Stainless steel cookware should not be used when preparing or cooking acidic foods such as tomatoes, vinegar, or citrus.
  • Vitamin C tablets can help prevent nickel from being absorbed in the gut. All other vitamins or supplements should be avoided.
  • Bottled or distilled water should be used for drinking and cooking.

 

[1] Mislankar M, BS, Zirwas MJ, MD. Low-nickel diet scoring system for systemic nickel allergy. Dermatitis. 2013;24:190-5.

 

Find out more about foods that contain nickel in our dedicated guide to a low nickel diet HERE.

 

dermatitis stories

Nickel-Allergic Patient Considering Hysteroscopic Sterilization

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Original article:

Bergman D., B.S., Goldenberg A. MAS, MD, Jacob S.E., MD Update on Providing Re-Essure-ance to the Nickel-Allergic Patient Considering Hysteroscopic Sterilization.

Review by Daniel Bergman, BS. MSIII, Loma Linda University

Nickel allergic contact dermatitis (Ni-ACD) has become a widely recognized disease process with an exponential increase in the last three decades within the United States. A subpopulation of ACD patients will manifest with systemic contact dermatitis (SCD) when exposed to nickel systemically such as orally, per rectum, intravenously, intravesically, transcutaneously, intrauterinely, or by inhalation. The Bergman et al[i] article highlights:

 

  • The FDA reports 212 incidences of EssureTM removal due in part to nickel allergy with 55% confirmed improvement of symptoms after removal.
  • Nickel allergy is not a contraindication for EssureTM, however, assessing for a history of moderate to severe reactions to nickel is crucial in reducing patient morbidity. This history should prompt further evaluation including possible referral to a specialist and patch testing.
  • The patch test is the gold standard for diagnosing ACD. In the hands of a trained professional the patch test is a proven predictor of ACD.
  • The pathophysiology is different between ACD and SCD. Therefore, not every woman with a history of ACD and a positive patch test will develop SCD to EssureTM.

 

[i] Bergman D., B.S., Goldenberg A. MAS, MD, Jacob S.E., MD Update on Providing Re-Essure-ance to the Nickel-Allergic Patient Considering Hysteroscopic Sterilization.