Unmask the facts- the truth behind “fragrance free”

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Original Article:

Scheinman PL. Exposing covert fragrance chemicals. Am J Contact Dermat. 2001;12(4):225‐228. doi:10.1053/ajcd.2001.28697

Reviewed by Jalal Maghfour and Dr. Alina Goldenberg

Fragrances are widely used in personal care products, cosmetics, medicaments, and foods within the US. Fragrances are responsible for many cases of allergic contact dermatitis, leading it to be perceived as a significant public health problem. 

We aim to provide an overview of fragrance chemicals and how knowledge of fragrance elements can shape patient outcomes.

Patch testing continues to be the gold standard for the diagnosis of fragrance sensitization. Patch test commonly include fragrance mix (FM) and balsam of Peru. FM, which includes cinnamic aldehyde, cinnamic alcohol, eugenol, isoeugenol, hydroxycitronellal geraniol, oak moss absolute, and alpha-amyl cinnamic aldehyde,  is highly ubiquitous worldwide with an estimated sensitization prevalence of 11%.  

While patch testing can detect 70 to 80% of fragrance elements, false negative reactions to FM may occur. Hence, it is important to conduct an expanded series of fragrance chemicals if the suspicion for an allergy is high. This is of clinical importance since identification of the exact etiology may guide disease management and empowers patients to take control over their own health.

Although being aware of fragrance allergy is important, many products that are labeled as “fragrance-free” are not truly free of chemical fragrance. For instance, benzyl alcohol is often used as a preservative but it is also considered a fragrance agent. However, because benzyl alcohol has a dual function, companies can legally label a product as “fragrance-free”. This makes it challenging for sensitized patients to avoid certain “fragrance-free” products.  Hence, knowledge of various products by clinicians can be vital for patient care. Historically, plant and animal ingredients were the main extracts used in making fragrance. It is therefore important to note that a patient who is allergic to a fragrance agent in a product may also react to the same ingredient found in plants and flowers.  

Sensitization to an allergen is necessary for elicitation to occur in which the rash of ACD is present. Initial sensitization usually requires a higher dose of the chemical allergen. However, if a fragrance is applied to skin areas with high absorption capacity such as face, genitals, and traumatized areas (shaving, post-surgical sites, excoriated lesions of atopic dermatitis/eczema), a lower dose is may be necessary to sensitize an individual. It is noteworthy that for sensitized individuals subsequent exposure of a lower dose of the allergen may be enough to elicit a cutaneous eruption. Hence, in addition to removing fragrances from commonly used products, public policy should also focus on reducing the levels of fragrance use to prevent reactions in sensitized individuals.

Nickel Navigator App

Achieve success with your low nickel diet

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In addition to the resources you can find at the Dermatitis Academy low nickel diet page, you can now increase your chances for success with the Nickel Navigator App. The app helps track your daily diet nickel intake! According to Rebelytics, the creators of the app, it is a “…support tool for individuals on a low-nickel diet.” The app helps you create a food journal to track your nickel intake. You can also browse though the food groups to see which foods are the lowest or highest in nickel, and you can search for a particular food and drill down into its data to understand how its nickel content varies. Rebelytics compiled this data from “more than 100 scientific sources, including national food studies and journal articles”. Interestingly, the average values can be weighted to the individual’s location so that the most geographically relevant sources are given priority. The app is easy to use, however for those that want to analyze the raw data this is readily available on their website.

TSW- awareness – one day at a time – TWO Free articles.

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Thank you to the authors and the two great publishers for allowing this limited time free access.

“More research is required into long-term topical corticosteroid use and its discontinuation, including topical steroid withdrawal, particularly in the pediatric population”… writes Dr. Belinda Sheary (Australia) who recently published an article describing “[a] qualitative case series [that] studied 10 children whose parents stopped their chronic topical corticosteroid use and subsequently developed features typically reported in adults experiencing topical steroid withdrawal.”

https://www.medicaljournals.se/acta/content/abstract/10.2340/00015555-3144

And…

Also this, month the Journal of the Dermatology Nurses’ Association featured a case of Topical Steroid Withdrawal in their regular column: Teledermatology Viewpoint. “Although the exact mechanism of TSW has not yet been elucidated, some experts suggest that prolonged application of topical corticosteroids interferes with the production of nitric oxide, a potent vasodilator, in the endothelium (Rapaport & Lebwohl, 2003) … On the other hand, an alternative explanation of symptoms of TSW is that prolonged topical steroid application may inhibit cortisol production by keratinocytes, which may weaken the barrier function of the skin as well as result in hypersensitivity (Fukaya, 2016).”

https://journals.lww.com/jdnaonline/Fulltext/2019/03000/Burning_Red_Face.8.aspx

Moisturizer may enhance hydrocortisone absorption

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Applying a moisturizing cream containing propylene glycol after applying topical hydrocortisone to the skin of patients with atopic dermatitis was shown to increase absorption of the glucocorticoid.

Original article:  Turpeinen,M.   Absorption of hydrocortisone from the skin reservoir in atopic dermatitis. British Journal of Dermatology. 1991; 124:358-360.

Reviewed by Allene Fonseca, PGY-3 Internal Medicine Resident Loma Linda University.

  • Turpeinen reported on the absorption rates of topical hydrocortisone applied to the skin of 7 patients (aged 4 months to 39 years) who were hospitalized for atopic dermatitis (AD) exacerbation.
    • Topical glucocorticoids were discontinued in all patients 36 hours prior to taking the absorption test.
    • A dexamethasone test was used to suppress morning cortisol secretion.
      • Dexamethasone is a strong steroid, 30-40x more potent than cortisol.
      • Administration of dexamethasone provokes (the body to have) a counter response of making less cortisol, because the homeostasis response sensed adequate corticoid in the system.
    • The serum level of cortisol of the 7 patients was checked after dexamethasone was given to suppress their natural cortisol production.
    • The dexamethasone suppression test was successful because all of the patients had below normal levels of plasma cortisol in the morning, compared to pre-treatment levels which were within normal limits.
      • To provide adequate suppression, the dexamethasone dose was adjusted to compensate for the percentage body surface area that had been receiving topical glucocorticoids previously.
        • For example, 0.25mg of dexamethasone was given for a body surface area of <0.5meters squared, and 2mg was given for a body surface area of >1.5 meters squared.
      • There were no noted side-effects of dexamethasone.
      • Subsequently, glucocorticoid absorption was determined by measuring serum cortisol levels, at set time intervals, beginning in the morning at 8:00-9:00, and subsequently 2h, 4h, 12h, 14h, 16h, and 24 h after the application of 1% hydrocortisone cream. In addition, the 3 adults’ serum was also checked again at 26 and 28 hours.
        • The cream was applied to the exact same areas that the topical hydrocortisone was applied too.
        • Children used 33-59g of topical hydrocortisone, and adults used 50-75g.
      • A moisturizing cream containing 80% water and 5% propylene glycol was applied to the hydrocortisone application sites, following the 12 hour blood sample.
      • In the adults, the moisturizing cream was again applied after the 24 hour blood sample was collected.
        • The changes in cortisol level between the different time intervals were statistically significant.
        • After applying 1% hydrocortisone once, plasma cortisol rose within 4 hours, and then steadily lowered.
      • In the 8 month old and the 3, 7 and 39 year old patients there was a rise in cortisol levels just 4 hours after applying the moisturizing cream, suggesting that within 4 hours the moisturizing cream can support increased absorption of topical steroid from skin reservoirs in some individuals.
      • In the 4 month old and the 19 and 20 year old patients there was not a significant rise in cortisol levels after applying the moisturizing cream
      • Following the 24 hour blood draw, the 3 adults again applied moisturizer.  There was no significant rise in serum cortisol levels. This finding suggests that applying moisturizer 24 hours after applying topical steroids does not increase the absorption of steroids.
    • This study suggests that topical hydrocortisone may be retained in the skin of patients with AD for up to 12 hours, and the absorption from the skin may be further enhanced by applying a moisturizing cream containing water and propylene glycol (PG).
      • PG, may work synergistically to increase the absorption of hydrocortisone (1).

References

  1. Turpeinen, M.   Absorption of hydrocortisone from the skin reservoir in atopic dermatitis. British Journal of Dermatology. 1991; 124:358-360.
  2. Zesch A. Schaeffer H. Penetration of radioactive hydrocortisone in human skin from various ointment bases. II. In vivo experiments. Arch Dermatol Forsch1975: 252: 245-56.

 

FREE Access – Medical Necessity of Comprehensive Patch Testing

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Free Access for 90 days, granted by publisher!!!

A Review of the Medical Necessity of Comprehensive Patch Testing

Zhu, Tian, Hao*; Suresh, Raagini†; Warshaw, Erin‡§; Scheinman, Pamela∥; Mowad, Christen; Botto, Nina**; Brod, Bruce††; Taylor, James, S.‡‡; Atwater, Amber, Reck§§; Watsky, Kalman∥∥; Schalock, Peter, C.¶¶; Machler, Brian, C.***; Helms, Stephen†††; Jacob, Sharon, E.‡‡‡; Murase, Jenny, E.**§§§

Abstract:
Allergic contact dermatitis is associated with significant disease and economic burden in the United States. To properly manage allergic contact dermatitis, it is important to accurately identify the substance(s) implicated in the dermatitis to prevent disease recurrence. The commercially available T.R.U.E Test (36 allergens) screening panel has been reported to have a conservative hypothetical allergen detection rate of 66.0%, at most. Importantly, these calculations are based on the 78% of patients who had clinically relevant reactions to allergens present on the North American Contact Dermatitis Group screening series (70 allergens), without the use of supplemental allergens. Testing with supplemental allergens beyond a screening series can more fully evaluate an individual’s environmental and occupational exposure, which may significantly increase diagnostic accuracy. Comprehensive patch testing with additional allergens in sunscreens, cosmetics, and fragrances, for example, may increase the diagnostic yield as well as the likelihood of achieving a cure if the dermatitis is chronic and recalcitrant.
Free access provided by LWW for 90days.

Link to Access

FREE- New Article on TSW!

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Systematic Review of the Topical Steroid Addiction and Topical Steroid Withdrawal Phenomenon in Children Diagnosed With Atopic Dermatitis and Treated With Topical Corticosteroids

Juhász, Margit L. W.; Curley, Rosemarie A.; Rasmussen, Annelise; Malakouti, Mona; Silverberg, Nanette; Jacob, Sharon E.

Background: A 2015 National Eczema Association study concluded that topical steroid withdrawal is an effect of prolonged, frequent use of topical steroids occurring mostly in adult women. It is unclear whether children develop topical steroid withdrawal.

Objective: The aim of this study was to assess current evidence regarding topical steroid withdrawal in children.

Methods: This study is a systematic review of medical literature as well as online social media sites and blogs regarding topical steroid withdrawal in children.

Results: Literature search yielded zero studies on/or reporting classic topical steroid withdrawal in children; however, periorificial dermatitis, which is generally a steroid-induced disorder in children, was reported in >320 cases. Of 142 social media blogs on topical steroid withdrawal, 26 were blogs discussing children. Twenty-seven cases were included in this review. Length of topical steroid use ranged from 2 months to 12 years.

Conclusions: Topical steroid withdrawal occurs in children and can result from discontinuing topical steroids used for as little as 2 months. Resultant signs/symptoms can last >12 months, even with short duration of use. Clinicians and caregivers should be aware of this possible adverse effect of topical steroids and monitor the effects of topical steroids on infants/children, but more data are needed on this condition.

 

Read it here – FREE for 30days – please share

Free Webinar – Complementary-Alternative Tx for eczema

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Webinar – Complementary and Alternative Treatments for Eczema
If you’ve ever looked up “how to treat eczema” on the internet, no doubt you’ve seen every type of diet, herb or ointment under the sun. Dr. Peter Lio is here to clear up the confusion by presenting those complementary and alternative eczema treatments that are shown to be effective through rigorous, scientific research. Register for free today.

Wednesday, September 13, 2017
5:00 p.m. PDT/7:00 p.m. CDT/8 p.m. EDT

Presenter
Peter A. Lio, M.D.
Clinical Assistant of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine

Moderator
Karey Gauthier, M.S.
Associate Director of Communications, National Eczema Association

T.R.U.E. Test (patch test) receives pediatric indication

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T.R.U.E Pediatric indication: T.R.U.E. Test (patch test) receives approval letter from Food and Drug Administration (FDA) for children 6 and older. After 12 years of investigations, evidence and data indicating that the patch testing is safe and efficacious in children suffering from recalcitrant dermatitis – the FDA has approved T.R.U.E Pediatric indication – the use of TRUE test to aid in the diagnosis of ACD in children.

This is the first commercially available patch test to receive approval for use in children 6 and older.  The T.R.U.E. test has 36 components, one is a negative control.

To read more about patch testing in children:

Article on Pediatric Allergic Contact Dermatitis.

“August 25, 2017

Dear Ms. Sullivan:
SUPPLEMENT APPROVAL PMR FULFILLED
August 25, 2017
We have approved your request dated October 26, 2016, to supplement your Biologics License Application submitted under section 351(a) of the Public Health Service Act (42 U.S.C. 262) for Thin-layer Rapid Use Epicutaneous Patch Test (T.R.U.E. TEST), to use as an aid in the diagnosis of allergic contact dermatitis in persons 6 years of age and older whose history suggests sensitivity to one or more of the 35 substances included on the T.R.U.E. TEST panels.”

FDA indication
Approval letter

MI contact allergy up!

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31689 patients evaluated —  the prevalence of contact allergy to methylisothiazolinone went up to around 20% in several departments!
2017 Jun 19. doi: 10.1111/jdv.14423. [Epub ahead of print]

“European Surveillance System on Contact Allergies (ESSCA): results with the European baseline series, 2013/14.

Uter W1, Amario-Hita JC2, Balato A3, Ballmer-Weber B4, Bauer A5, Belloni Fortina A6, Bircher A7, Chowdhury MMU8, Cooper SM9, Dugonik A10, Gallo R11, Giménez-Arnau A12, Johansen JD13, John SM14, Kieć-Świerczyńska M15, Kmecl T16, Kręcisz B15,17, Larese Filon F18, Mahler V19, Pesonen M20, Rustemeyer T21, Sadowska-Przytocka A22, Sánchez-Perez J23, Schliemann S24, Schuttelaar ML25, Simon D26, Spiewak R27, Valiukeviciene S28, Weisshaar E29, White IR30, Wilkinson SM31.

Abstract

BACKGROUND:

Contact allergy is a common condition and can severely interfere with daily life or professional activities. Due to changes in exposures, a consequence of introduction of new substances, new products or formulations, and regulatory intervention, the spectrum of contact sensitisation changes.

OBJECTIVE:

To evaluate the current spectrum of contact allergy to allergens present in the European baseline series (EBS) across Europe.

METHODS:

Retrospective analysis of data collected by the European Surveillance System on Contact Allergies (ESSCA, www.essca-dc.org) in consecutively patch tested patients, 2013/14, in 46 departments in 12 European countries.

RESULTS:

Altogether, 31689 patients were included in the analysis. Compared to a similar analysis in 2004, the prevalence of contact allergy to methylisothiazolinone went up to around 20% in several departments. In comparison, contact allergy to the metals nickel, cobalt and chromium remained largely stable, at 18.1, 5.9 and 3.2%, respectively, similar to mostly unchanged prevalences with fragrance mix I, II and Myroxylon pereirae (Balsam of Peru) at 7.3, 3.8 and 5.3%, respectively. In the subgroup of departments diagnosing (mainly) patients with occupational contact dermatitis, the prevalence of work-related contact allergies such as to epoxy resin or rubber additives was increased, compared to general dermatology departments.

CONCLUSION:

Continuous surveillance of contact allergy based on network data offers the identification of time trends or persisting problems, and thus enables focussing in-depth research (subgroup analyses, exposure analysis) on areas where it is needed.”

This article is protected by copyright. All rights reserved.

https://www.ncbi.nlm.nih.gov/pubmed/28627111

New Nickel Quiz

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Take this new Nickel Quiz and test your savvy.  A study of 125,478 people with a nickel sensitivity, showed that developing allergic dermatitis, increases the risk of multiple sensitizations.

The quizzes are an educational endeavor created by the DA scholars to help promote awareness of contact dermatitis.

Nickel Quiz Here

Loma Linda University researchers are investigating the impact of nickel allergy – please share the nickel allergy survey and increase the knowledge…

Nickel Allergy Survey

 

Thank you!