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.

Test Your Propylene Glycol Savvy – Which of these items might contain propylene glycol?

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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 Contact Dermatitis

Nickel Contact Dermatitis in US Adults-A 53-Year Review- Synopsis

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Authors: 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.

Synopsis by Janna Vassantachart, MSIV — Loma Linda University School of Medicine

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. 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. 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.

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TEST YOUR ISOTHIAZOLINONE SAVVY – WHICH OF THESE ITEMS HAVE BEEN REPORTED TO CONTAIN AN ISOTHIAZOLINONE (MCI/MI/BIT)?

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Amanda’s Allergic Contact Dermatitis Story – My ACD story

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Amandasstory

“My MI/MCI story by Amanda B.

In April of 2013, I began struggling with sleep. Friends suggested I go on Hormone Replacement Therapy, and my doctor, who knew nothing about hormones, suggested I visit a gynecologist for HRT. She also offered me sleeping pills. Not wanting either alternative, I chose to hope for the best and tough it out. But months and months later, I still wasn’t sleeping, and my thoughts and feelings began to become affected. The day before Thanksgiving, my only surviving family member and sibling was admitted into the hospital 2,000 miles away. She passed away on December 11 and I was unable to attend her funeral.  My college-aged children were home and I pressured myself into preparing elaborate holiday feasts. My business, which is in full swing during the holidays, was demanding my attention. I say all of this so you can understand that I was on overload, to say the least. I fully believe that my sensitization to MI/MCI was due in large part to stress, the fact that I wasn’t handling my stress well, and my use of denial (“it will all get better”).

That Christmastime, I began experiencing itchy rashes on the back of my hands. I was at a loss as to what was causing it. I booked a January appointment with a dermatologist and they kind of shrugged, gave me a preliminary diagnosis of dyshidrotic eczema (although the presentation of my rashes was irregular for that diagnosis), gave me some very strong ointment, and sent me on my way. I read the package insert of the medication and was alarmed at how they stated it could interfere with the adrenals. I used it sparingly, and it worked.

I kept having these sorts of breakouts on my hands, but then later in 2014, I began breaking out on my face, chest and arms. These blisters were horrible. As the rash on my face was in a butterfly shape, the dermatologist tested me for Lupus, which was negative. No indication on their part as to what could be causing the rashes. More corticosteroids.

Finally in early 2015, after a facial caused my lips to flare, I insisted we get to the bottom of the problem. The dermatologist suggested a patch test to determine if I had contact allergies. She administered the TRUE test and I reacted quite strongly, and only to isothiazolinone. Not one person in the office could pronounce it, and not one person talked with me about Allergic Contact Dermatitis (ACD). They handed me a printout from the TRUE test and said, “this is what the problem is.” I immediately talked with the aesthetician who had given me the facial. She began looking on her phone right away. The first site she went to was Wikipedia, and then she went to Facebook. She found the MI group and I immediately began following. To date, these MI support groups have provided me with nearly 100% of my education on ACD.

Like everyone else with ACD, the allergy ruled my life at first (and it still does, for the most part, but I have a safe home now, and I know how to live with the diagnosis). I spent a great deal of time focusing on how to keep out of a flare. I am a jewelry artist and am exposed to chemicals on a regular basis, but it was cleaning out my basement this past winter that caused a huge flare that I couldn’t seem to heal. Although I have prescriptions for various corticosteroids, I try to use them sparingly, even to wean myself off of them, because they are known for thinning the skin, and the ingredients are absorbed into the bloodstream. So during this particular flare, I began using natural salves that were absolutely lovely (in my opinion). But something wasn’t right. I would use corticosteroids one night, the natural salves another night, and I kept flaring. There was no MI/MCI in any of the products I was using. So back to the dermatologist. She had mentioned that there was a specialist about an hour and a half away who could patch test me on a larger scale if I needed it, so I said, “it’s time”. Fortunately, I have medical insurance that would pay for it.

In April of 2016, I had my appointment and was given 129 patches on my back. The results were that I had developed sensitivities to some of the ingredients in the natural salves I had been using. My new allergens include Fragrance II, Propolis, the botanicals neroli and lemongrass, as well as ethylhexylglycerin and dodecyl gallate. I was told to avoid all fragrances, all botanical oils and beeswax, in addition to MI/MCI.

Now I use very little on my skin, as I fear that I will become sensitized to more allergens. Something that I feel has been missing in all of this is patient education about how to heal a flare once you get one. And that education for the medical community in this arena is sorely lacking. I know that doctors become highly specialized and it may be impossible for them all to know about ACD, but it seems to me that dermatologists ought to be able to patch test a patient sooner than later.   I think that most of us ACD sufferers are out there floundering with no idea of diagnosis and treatment. I am grateful that Dermatitis Academy exists now to help us all through this maze!”

My Allergic Contact Dermatitis (ACD) Story is a portion of the Dermatitis Academy Blog that highlights real life, user submitted, allergic contact dermatitis journeys in an attempt to provide awareness and encouragement regarding this crippling disease.

Infographic by Peter Gust

Claire's Story

Parent’s Speak Out About Allergic Contact Dermatitis and Patch Testing

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Claire's Story

It Just Kept Coming Back

“From a very early age, my daughter had eczema. Hers was a very mild case; sometimes she would get small patches on the back of her knee or on her wrists, other times her skin was perfectly clear. Each night that she had a bath, I made sure to fully moisturize her skin in order to protect it and if needed I would put a small amount of hydrocortisone on affected areas. This usually did the trick and her skin stayed pretty healthy looking. I didn’t want my daughter to suffer from itchy and uncomfortable skin…and I certainly wasn’t going to let that happen. After all it was my job as a mother to keep my child healthy, comfortable and happy. Her skin was great for about 10 years, with a few manageable flares every so often.

 

As time passed and as my daughter entered upper elementary school, her skin gradually became worse. I continued to treat her skin with the same moisturizer and hydrocortisone cream. Sometimes it would get a little better, but then it would come back worse than the previous flare. She also became much more uncomfortable, it seemed like she was always scratching herself. I noticed more and more scratch marks each day she woke up.   We were doing everything that had been suggested…frequent lukewarm baths, pat dry, hydrocortisone, moisturize, a cool temperature in the bedroom, cotton pj’s, and we kept her fingernails short. Still, it got worse.

 

At one point we had to go to the pediatrician because the backs of her knees were weeping…and it happened seemingly overnight. She was given antibiotic ointment, oral antibiotics, and a new steroid to help calm everything down. Once it calmed down we went back to the same skin care routine.

 

The condition of her skin continued to decline. The areas around her eyes became dry and scaly at times. It was frustrating trying to apply makeup for dance recitals, as the flakes were so much more visible with her makeup on. Her shins became unmanageable. She literally couldn’t sit still with out scratching or rubbing her legs, back, arms, neck or face. It drove me crazy and I drove her crazy as I told her over and over to stop scratching. She knew she shouldn’t scratch but the itch was unbearable. We had so many battles about her skin…it was seriously affecting our relationship and many nights ended in tears for both of us.

 

When we first went to see the dermatologist she looked at her skin and asked us questions about what we had been doing to treat the eczema. She said that an injected steroid would help calm things down, so we opted for that. She also prescribed a stronger steroid and a topical immunosuppressant cream for her eyes. She assured us that we were ok to use the steroid cream, and offered advice on tapering down, and which strength of steroid to use on different areas of skin depending on severity of the condition.

 

Her skin cleared nicely after the shot and the stronger topical steroid. The topical immunosuppressant seemed to work temporarily, but the skin always returned to a flaky and inflamed condition without it. Eventually, the rest of her skin was back to its previous state, and getting worse by the day.

 

At the next dermatologist appointment, the doctor looked at the condition of the skin and said, “Did you ever have her patch tested?”. I had not heard of patch testing and didn’t know anything about it. She went on to explain that it is a test that can diagnose allergies to substances that she might be coming into contact with that are responsible for creating her dermatitis. She gave me the name of local dermatologist that performs patch testing. We left from the appointment with a few new samples of products, the same treatment plan, and the name of the contact dermatologist.

 

Did I schedule the patch testing right away? No, I did not. (Looking back I wish I would have dialed that number as soon as we had left that appointment) I thought, “We’ll give it a little more time to see if it clears up.” All the while my daughter was miserable. As I was putting her steroid cream on one night she said, “Mom, are you sure this is making it better?” My quiet and uncertain response was, “It’s supposed to.”

 

Finally, mid summer, we scheduled a patch test consultation. We met with a nurse practitioner who was under the guidance of the contact dermatologist. She explained the patch test procedure and what my daughter could and couldn’t have as far as topical and oral medications, and also explained the need to limit sun exposure prior to and during patch testing. The dermatologist joined our meeting later and asked us questions about when her condition started, asked if we had trouble with her ears as they had been pierced, and just general questions about possible exposure to allergens.   We scheduled my daughter’s patch testing for the week before she would return to school.   It would take one full week with four appointments to complete the test, as our insurance required half of the patches to be applied the first day, and half applied at the second appointment, two days later.

 

I assumed my daughter would want to hang out around the house during patch testing. After all, she was a middle schooler, a vulnerable age for so many girls in regards to appearance. But no, she put on her dance leotard with her patches showing and went to her studio for dance class. She explained to everyone what the patches were and was able to make jokes and laugh about it with her friends.

 

At our third patch test appointment when both sets of patches had been removed, the doctor indicated that he thought that he would be able to give us some helpful information at the final appointment on Monday. When we got the results at the final appointment, we learned that she was allergic to 10 substances! Nickel, Propylene Glycol, Methylisothiazolinone, Parabens, BHT, Oleamidopropyl Dimethylamine, Lanolin, Octyl Gallate, Bronopol, and Decyl Glucoside. Some of these had elicited stronger reactions than others, but the doctor felt that they were all clinically relevant.

 

It turns out that many of the substances that she was allergic to were ingredients in the moisturizers, steroid creams, and the topical immunosuppressant cream that we had been using. The very things that we were using to treat her eczema were making it worse! It was explained to us that no one is born allergic to these substances, but through exposure one becomes allergic. So, not only were these ingredients making her skin worse – these substances were in fact responsible for creating the allergic contact dermatitis that my daughter was suffering from. The seemingly hypoallergenic and safe products that I was using on my daughter’s skin, from the time she was a baby, created this nightmare of a condition. When this revelation had time to sink in, I became deeply saddened and outraged.

 

As I came to grips with all of this new information I began to remove her allergen containing products from our lives and replaced them with “safe for my daughter” products.   I learned that in order for my daughter’s skin to have the best chance for healing, we needed to completely avoid all exposure to the substances that she tested allergic to. We changed out personal and household products, eliminating every product that contained her allergens. I changed my products as well so that there wouldn’t be risk of exposure to her from a product that I had used on myself.

 

As we evaluated every possible place of exposure, my daughter informed me that one of her teachers at school was using an automatic air freshener in the classroom. Air fresheners contain all sorts of contact allergens…and in my daughter’s case, propylene glycol and methyliosthiazolinone would be the worst offenders in this kind of product. She didn’t want me to talk with her teacher about it, as the air freshener was one of the things that he was known for, and he was a popular teacher with the students. I told her that I had to, and it that it was the school’s obligation to provide a safe environment for ALL of the students. I e-mailed her school counselor and she responded with a phone call within an hour of receiving the email. She understood the situation at hand, and immediately suggested to get a 504 plan in place.

 

At the 504 meeting, I brought my daughter’s binder containing all of the papers we had received at her patch testing appointment. I also showed the teachers and counselors pictures of allergic contact dermatitis reactions. I explained that some of these chemicals are in aerosols and cleaning supplies commonly used at school and at home. The teacher who had the automatic air freshener in the classroom looked up ingredient listings for the household wipes and other cleaning products used at school.   It was eye opening for him to see the prevalence of these chemicals in products.   As a result of this meeting the educational team had a better understanding of allergic contact dermatitis and they all agreed a 504 plan would be appropriate. We ended up with a comprehensive plan at the end of the meeting. The teachers would use a simple dilute bleach/water solution and paper towels to sanitize and clean desks. The head cafeteria worker would investigate the cafeteria cleaning supplies and report back to us. And the teachers were ecstatic about this one: “Scent Free Zone” signs would hang on the walls of the halls and classrooms in my daughter’s wing of the building. The teachers were excited about the possibility of the elimination of body spray being applied by the boys in the locker hallways.   The teachers were very accommodating and I couldn’t have been more pleased with their response.

Before/After…

beforeclaire after

Through continued avoidance of my daughter’s contact allergens, and with time allowed for healing, her skin looks better than it has in many years, and more importantly, she is more comfortable than she has been in many years. I realize now the significance of that one simple question that our dermatologist asked: “Did you ever have her patch tested?”  If she hadn’t mentioned patch testing, my daughter would likely still be suffering today. Patch testing, diagnosis, and removal of allergens has been the key to my daughter’s recovery.”

 

  • By Misha B.
  • Infographic by Peter Gust

 

Parents Speak Out About Allergic Contact Dermatitis (ACD) is a special category in the Dermatitis Academy Blog where passionate parents reveal a personal look their family’s journey in dealing with ACD and the role of the patch testing.

 

Please visit our home page HERE for more information on allergic contact dermatitis. Please share this post in order to create awareness for this seldom considered, but highly relevant disease process.

Remington's Story

Remington’s Story – Parents Speak Out About Allergic Contact Dermatitis – Benefits of Being Patch Tested

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Remington's Story

“Is that contagious? A question we have been asked throughout my son’s life.  I am sure many people with skin issues have heard frequently!  Our son is just shy of three years old and has been battling a skin issue since he was a few months old.  Once he turned a year old his skin began to get worse. As months continued it even worsened, soon it was to the point that we could not take him out. Doctor appointments weekly sometimes multiple doctors appoints in a week. Specialist after specialist nothing was working.  He was diagnosed with eczema at just 6 months old. We were first prescribed over the counter medications. But as he continued to get worse something else needed to be done. Once he reached a year old we were sent to an Allergist. They performed a skin prick test on his back. They found him to be mildly allergic to dog. The allergist changed up his medication yet again.”

Remington's story

“As the months rolled by he was not getting better, if anything he was getting worse. We were finally sent to a dermatologist. There they performed a blood test on him to find allergies.  Yet nothing came back positive except for dog.  They continued to treat him as if he had “eczema” at one point he was on three different steroid creams. We would rotate Zyrtec, Benadryl and Attarax just to try and relive his itch. Our nights became nightmares are sleep became nonexistent. There were endless hours of tears. Nothing we did would work. NOTHING! We were hospitalized for 5 days. He also had a staph skin infection. Even the bleach baths weren’t working at this point. Our son was prescribed prednisolone so many times in 6 months that he reached his peak for oral steroids and the doctors would not prescribe him them again. I honestly felt like I was feeding my child medications for no reason. The flare ups became worse and lasted longer. It was truly a nightmare! Once we reached the max limit on oral steroids his dermatologist decided that it was time to start an immune-suppressant.  This was something we were completely against. We felt his immune system was already weak and we were not willing to go this route. We wanted a second opinion. We changed his pediatrician; we needed a new set of eyes.”

“The new pediatrician did a complete blood work profile on him. His live vaccinations titers came back as if they were not existent.  He was given a booster then had his levels checked a few weeks later. They came back normal, so the route of having an auto immune disease was out. Still getting new creams and ointments nothing was working. At this point we said we are done with steroids. We went all-natural. We were doing herbs and using only coconut oil on his skin. It seemed to be working but then it was infection after infection. After 4 months or so he wasn’t improving. He was one of his worst flare ups we had to go back to the dermatologist. We couldn’t put it off anymore we had to give it a try, we had to give our child some type of relief. We did it. We put him on cyclosporine. He was going for blood work weekly to start. This medication is used in transplant patient and monitoring of kidneys and liver function are needed while on this medication, his levels needed to be checked frequently. At first it seemed promising he seemed to be doing slightly better. We thought we were seeing the light at the end of a DARK tunnel. But then it hit, yup you guessed it – another flare up. This time worse than the last. He was at the doctors 3 times in a week. Eight different medications – it was heartbreaking. What am I doing wrong; I asked myself this question so many times. I didn’t understand why wasn’t anything working. I knew something I was wrong I knew this wasn’t just “eczema” I knew it was more!”

“He was on cyclosporine for about three months; usually this clears up something with eczemas fairly quickly, but not us. That’s when I decided it’s time for another set of eyes. I contacted at Children’s Hospital which was three hours from us. I scheduled and appointment but it was 6 months out. Our pediatrician called them on our behalf because he wanted him to be seen as soon as possible. We got in the next week! As soon as we got in the room the dermatologist looked at him and said has he ever been patch tested for contact allergens, he needs to be patch tested. She knew right away he had a contact dermatitis rather than atopic dermatitis. We had the patch testing done. Mind you we have to drive a total of 6 plus hours there and back, but we went through with it. We NEEDED answers. Leaving that doctor appointment I felt a sense of surety, I honestly felt like we were achieving some. I felt a sense of relief. My husband took our son back down on Friday. We had his final read on Monday. GUESS WHAT – our son tested positive for 3 different allergens. He was positive for propylene glycol, compositae (asterace), and sesquiterpene lactone. Finally we got answers, because he was patch tested! So the reasons the all-natural route did not work was because it had sunflower base in it (sunflowers are in the Composite family and contain sesquiterpene lactones).

He is allergic to florals and herbal things. The reason the cyclosporine did not work may have been because it contained PG, but also because he was unknowingly being exposed to his allergens. Also two of the steroids as well as moisturizers he used contained PG. After he was patch tested, we had to clean out our house. I went home and got rid of everything. If it smelled it was removed to prevent further damaging his skin. I love the scentsy smelly things, but they were gone, no if and or buts! I went through all the cleaning supplies I had checked every label. We took him off all medications and ointments. We put him on an ointment free from PG. We had a game plan. Within a week we could see a difference. It was amazing. We are now on a normal bed time routine. We actually get sleep, it is a miracle. His hands, feet and face still have healing to do but it is manageable and I know we can do it. If it wasn’t for Patch Testing, I don’t know where we would be right now. Patch testing has truly given my son the gift of being able to be a child again!”

 

  • by Travis & Jessica Musser
  • Infographic by Peter Gust

 

Parents Speak Out About Allergic Contact Dermatitis (ACD) is a special category in the Dermatitis Academy Blog where passionate parents reveal a personal look their family’s journey in dealing with ACD and the benefits of being patch tested.

 

Please visit our home page HERE for more information on allergic contact dermatitis. Please share this post in order to create awareness for this seldom considered, but highly relevant disease process.

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.