Bulb dermatitis

The irritant and allergenic properties of the most important flower bulbs are described, as well as the clinical symptoms they cause. The tulip contains the allergen tulipalin A: sensitization and irritation are responsible for the development of tulip fingers. The same clinical picture can be caused by Alliums like the onion and garlic. The narcissus causes lily rash, a dermatitis rarely caused by sensitization. The hyacinth evokes itching in practically everyone: an irritant reaction caused by calcium oxalate crystals. Patch testing is complicated as the allergens are not all identified.     

Occupational irritant and allergic contact dermatitis among healthcare workers

Contact dermatitis is the most frequent occupational dermatosis and non-specific irritants in addition to specific Type IV sensitization are involved. We reviewed our database for data from 1994 to 1998 and selected 360 consecutive patients working in healthcare environments and experiencing contact dermatitis at their hands, wrists and forearms. We found that allergic contact dermatitis and irritant contact dermatitis were considered to be work-related in 16.5% (72/436) and 44.4% (194/436) of diagnoses, respectively. Occupational irritant contact dermatitis is due to exposure to a wide range of irritants in the workplace, such as soaps, solvents, cleansers and protective gloves, which conspire to remove the surface lipid layer and/or produce cellular damage. In this study the major relevant aetiological agents that induced occupational allergic contact dermatitis were: nickel sulphate (41 patch positivities), components of disinfectants [glutaraldehyde (5) and benzalkonium chloride (7)] and rubber chemicals [thiuram mix (15), carba mix (9) and tetramethylthiuram monosulphide (6)]. The best treatment for allergic contact dermatitis is to avoid those allergens causing the rash. Whenever this is not possible, contact with them needs to be reduced using properly selected protective gloves. Finally, subjects with atopic dermatitis should avoid 'wet work' and contact with irritants, because atopic dermatitis is significantly associated with irritant contact dermatitis.     

Occupational food-related hand dermatoses seen over a 10-year period

Background. Protein contact dermatitis was originally defined in 1976 by Hjorth and Roed‐Petersen as a distinct kind of dermatitis seen in patients with occupational food contact. Even though occupational skin diseases are frequent in Denmark, little attention has been paid to protein contact dermatitis, and the frequency is unknown. Objectives. To evaluate the frequency of occupational food‐related hand dermatoses and test results in patients occupationally exposed to foods. Materials and Methods. This was a retrospective study based on examinations, including skin prick testing and patch testing, performed at the Department of Dermato‐Allergology, Gentofte University Hospital, Denmark between 2001 and 2010. Results. Of all patients (n = 372), 57.0% had irritant contact dermatitis, 22.0% had protein contact dermatitis, 2.4% had contact urticaria, and 1.8% had allergic contact dermatitis. A suggestion for diagnostic criteria is presented. Frequent risk occupations were cooking in restaurants, baking, and kitchen work. Substantially more patients reacted in skin prick testing with fresh foods than with food extracts. Conclusion. Protein contact dermatitis is a frequent disorder among patients who professionally handle foods, and should be considered to be a distinct clinical entity. When diagnosing protein contact dermatitis and in other food‐related skin prick testing procedures, it is important to include fresh foods.     

Dermatoses in metal workers

In an epidemiological study of 286 metalworkers exposed to metalworking fluids (MWF), the prevalence of skin problems was investigated. Minor changes, such as a dry rough skin with slight erythema, were seen in 31%, and major changes, such as more serious and widespread dermatitis, were observed in 27% of all workers. By far the most cases were of irritant origin; in only 2.8% was a contact sensitization established. Exposure to water-based MWF caused irritant contact dermatitis more often than exposure to neat oils. No influence was found of the presence of atopy on the occurrence of dermatitis. Other factors that may result in irritation of the skin are discussed, as well as measures to be taken to minimize insult of the skin.     

Occupational hand dermatitis in hospital environments

Health care personnel form the 5th category at major occupational risk of skin disease in Italy The aim of this study was to assess the prevalence and clinical relevance of contact dermatitis in a group of 1301 employees of the Perugia Monteluce Hospital (658 females and 643 males: mean age 39.8 years) who answered a self-administered questionnaire elaborated by the authors. The subjects with anamnestic hand dermatitis and/or atopic mucosal reactions were clinically examined and submitted to skin tests (patch and/or prick tests). Contact dermatitis of the hands and/or forearms occurred in 21.2% and was significantly more frequent (P < 0.001) in women, subjects under 31 years of age, workers in internistic and surgical fields, cleaners and nurses. In the majority of cases (94.9%) the lesions were irritant in origin and mainly related to disinfectants (especially, chlorhexidine gluconate and glutaraldehyde) and gloves (latex proteins and starch glove powder. rather than accelerators and additives of rubber), Finally, atopy seemed to favour the onset of hand dermatitis, The importance of these results for preventive measures of contact dermatitis in hospital employees is discussed.     

A temporary henna tattoo causing hair and clothing dye allergy

Contact dermatitis following the application of temporary paint-on henna tattoos indicates a potentially serious problem of active sensitization. We describe 2 cases involving sisters who travelled to Bali together and acquired a temporary black henna tattoo to the lower back region. Both sisters subsequently developed a contact dermatitis at the tattoo site, the dermatitis disseminating in one sister. There was persistent hyperpigmentation at the tattoo site in both sisters several months after the application. Patch testing revealed a positive reaction to para-phenylenediamine (PPD) in both sisters. One sister also showed reactions to other hair dyes and to multiple organic dyes. Allergic contact dermatitis to PPD contained in temporary henna tattoos is an increasing problem worldwide, with cross-reaction to related compounds and permanent skin changes, a frequent consequence of sensitization to this significant allergen.     

Relationship between 2,4-dinitrochlorobenzene elicitation responses and individual irritant threshold

Contact dermatitis shows significant interindividual variation. We studied the relationship between an individual's irritant threshold and the elicitation of experimentally induced allergic sensitization. The results suggest that there is an association between reactivity to an irritant and the likelihood of positive elicitation reactions to lower hapten concentrations. This novel finding would be compatible with the proposal that contact allergy is best explained using a danger model with cutaneous irritancy determining sensitization. However, the enhanced allergic reactivity of individuals with a lower irritant threshold was not apparent on visual inspection, suggesting that the determinants of skin reactivity to haptens are multifactorial.     

Contact dermatitis

Contact dermatitis is a common skin disease caused by contact with irritants or allergens. Irritant contact dermatitis is a result of nonspecific irritant factors, which cause activation of mainly innate immunity, resulting in skin inflammation. Contact hypersensitivity, which manifests itself as allergic contact dermatitis, is result of adaptive immune response, where sensitization to hapten-carrier complexes leads to T-cell-mediated contact allergy. Subsequent contact with the hapten results in skin inflammation. This review concentrates on the role of cutaneous receptors in contact dermatitis and highlights potential targets for treatment interventions.     

Contact dermatitis of the vulva

Contact dermatitis of the vulva is common, with irritant contact dermatitis occurring more frequently than allergic contact dermatitis. Patients with chronic vulvar dermatoses are at greater risk and should continually be reassessed for possible contact dermatitis. Comprehensive and specific questioning about hygiene practices and product use is necessary to elicit a history of contactant use. Patch testing is required to identify relevant contact allergens, the most common of which include medicaments, preservatives, and fragrances. Patient education and follow-up are essential in optimizing treatment and preventing recurrence of vulvar contact dermatitis.     

Dermatoses in metal workers

In an epidemiological study of 286 metalworkers exposed to metalworking fluids (MWF), the prevalence of contact sensitization was investigated. In part I, irritant contact dermatitis in metal workers has been discussed. In 40 employees with dermatitis, patch tests were performed with a routine series, a series of common components of MWF, and a series of preservatives the employees worked with. Contact sensitization was established in 8 persons (2.8% of all workers), of whom 4 were allergic to biocides and/or corrosion inhibitors. Difficulties in interpretation of the relevance of positive reactions are discussed. Attention is paid to the use of biocides in MWF, their various types and their sensitizing capacities. Measures to reduce the induction of contact sensitization to preservatives in water-based fluids are discussed.     

Adverse skin reactions to nicotine in a transdermal therapeutic system

Nicotine in a transdermal therapeutic system (TTS) has been introduced recently to help people to stop smoking. 14 volunteers (10 male, 4 female) with a history of former adverse skin reactions to this device were investigated. Skin tests for contact urticaria and patch tests for contact allergy were done with the individual components of the TTS. Contact sensitization to nicotine was identified in 5 and to the TTS itself in 1 individual. Irritant reactions due to occlusion were present in 9 subjects. The optimal test agent and concentration for elucidating the adverse skin reaction was an aqueous solution of 10% nicotine base. Atopy, as diagnosed by history and skin prick tests to common inhalant allergens, and contact sensitization to standard patch test allergens, were each identified in 6 subjects. Nicotine should be added to the expanding list of transdermally delivered drugs which may elicit contact dermatitis.     

Anogenital allergic contact dermatitis, the role of spices and flavour allergy

Background: In patients with vulval or anogenital dermatitis, irritant contact dermatitis is more common than allergic contact dermatitis. The reported frequency and relevance of contact sensitivity in anogenital dermatitis varies greatly. Objective: To determine the frequency and relevance of contact sensitization in a Dutch group of female patients with chronic anogenital complaints. Methods: We reviewed patch test results of 53 women with chronic anogenital complaints, with sole vulval symptoms in 29 women and sole perianal in 5, in whom inflammatory skin diseases like lichen sclerosus, lichen planus, psoriasis, as well as infectious diseases were unlikely or excluded as a cause of their symptoms. All women were tested with the European baseline series plus additional test series according to their personal history. Results: Thirty‐five patients (66%) showed one or more positive test reactions. Seven of these patients (20%) had one or more clinically relevant positive reactions, most often to flavours and spices. Conclusion: A considerable number of patients with anogenital dermatitis have a contact sensitization. Clinically relevant reactions were mainly found to spices and flavours. This is in contrast to the data reported in the literature that shows most contact allergies in vulval patients to ingredients of topical medication.     

CONTINUING MEDICAL EDUCATION REVIEW Occupational skin disease in hairdressers

Hairdressers belong to an occupational group that is commonly affected by occupational skin disease, specifically contact dermatitis, which may be allergic or irritant and, less commonly, contact urticaria. Occupational contact dermatitis predominantly affects apprentices, and atopy is a recognized risk factor associated with a poor prognosis. Repetitive wet work leading to irritant contact dermatitis, followed by exposure to allergens and the development of allergic contact dermatitis, are the main factors contributing to occupational contact dermatitis. Once developed, it is often difficult to manage and is a cause of significant morbidity. Early education, training and prevention is the best approach to the management of this disorder that is endemic among hairdressers.     

Tertiäre Prävention von Berufsdermatosen

Background: Inpatient tertiary prevention of occupational skin diseases is indicated when the employee is threatened with loosing their job. Earlier studies have shown that with intensive tertiary preventive measures, 2/3 of such individuals can continue their jobs long‐term. Data on the effectiveness of tertiary prevention for various occupational groups has not been previously available. Patients and Methods: The outcome of all participants treated in the year 2002 was analyzed according to occupational groups with respect to diagnosis, medical intervention prior and during the inpatient period. Results: In 91 % of 296 cases contact dermatitis of the hands was diagnosed (75 % primary irritant contact dermatitis (37 % chronic irritant contact dermatitis, 38 % irritated atopic hand eczema, 16 % allergic contact dermatitis). Clinically relevant Type IV‐delayed hypersensitivity (allergic contact dermatitis) reactions were identified in 42 % of cases; in most cases, the delayed hypersensitivity followed irritant contact dermatitis. In more than 83 % of cases, a complete or nearly complete remission was achieved. Clinical relevant Type IV sensitization was most frequent in hairdressers (66 %). Cleaning and housekeeping personnel most frequently used corticosteroids on a regular basis (60 %) and most often experienced corticosteroid withdrawal (53 %) and atrophy of the skin of the hands (23 %). Conclusion: The data from studies on the tertiary prevention of occupational skin diseases reveal strategies for the optimization of outpatient care indicate specific occupational risk factors. The variance between professions may reflect differing approaches to secondary prevention.     

A comparison of expression of surface-bound immunoglobulin E on antigen-presenting cells in cutaneous tissue between patients with allergic, irritant and atopic dermatitis

The expression of surface-bound immunoglobulin E by dendritic cells within cutaneous tissue has been compared in atopic and contact dermatitis. 45 patients were recruited into 4 groups using clinical criteria and patch testing to a standard series of allergens: atopic (12 cases), allergic contact dermatitis (14 cases), irritant contact dermatitis (10 cases) and the control group (9 cases); using clinical criteria and patch testing to a standard series of allergens. Skin biopsies from each patient were analysed by the indirect immunofluorescence technique. This differentiated 3 patterns of cutaneous IgE distribution: (i) no detectable cutaneous IgE; (ii) detection of IgE solely within the dermis; (iii) detection of IgE within both epidermis and dermis. Detection of IgE within the epidermis was always associated with the presence of IgE within the dermis. In each case, IgE was surface-bound by dendritic cells. Immunoglobulin E was detected within both epidermis and dermis in skin biopsies from 8 (66.7%) atopic patients and 2 (20%) patients with irritant contact dermatitis. No other cases demonstrated IgE deposition within both the epidermis and dermis. Atopic patients were significantly more likely to have detectable IgE deposition, within both epidermis and dermis, than patients with contact dermatitis (allergic and irritant groups combined, p = 0.0011) or controls (p = 0.0049). This finding suggests that the demonstration of IgE within both epidermis and dermis supports a diagnosis of atopic dermatitis. It would therefore be of value in differentiating between atopic and contact dermatitis, where clinical diagnosis is in doubt.     

Self-reported skin symptoms in metal workers

Machinists and machine maintenance men working in the metal industry use metal-working fluids capable of causing irritant and allergic contact dermatitis. The objectives of this study were to find out the frequency of skin symptoms in machinists and machine maintenance men (metal workers) and to compare the risk of their skin symptoms to that in office workers (controls). A total of 726 male metal workers and 84 controls answered a structured telephone questionnaire enquiring about work, atopy, skin symptoms, their impact on life, etc. The risk of skin symptoms compared with that in the controls was estimated using a logistic regression analysis. Of the metal workers, 20% reported recurring or prolonged dermatitis on their hands or forearms during the past 12 months. The hand or forearm dermatitis (HD) affected mostly the metal workers' mood and their activities at work. Recurring dermatitis elsewhere (DE) than in the hands and in connection with work was reported by 10%. The risk of HD was about twofold and the risk of DE was about fourfold compared with that in the controls. The HD of machinists may be severe and affect their ability to work. DE may have clinical significance in machinists.     

Periorbital dermatitis: Causes,differential diagnoses and therapy

Periorbital dermatitis is common and frequently difficult to treat. Patients with periorbital dermatitis often suffer severely because their disease is in such a visible location. Because of the variety of clinical appearance, the differential diagnostic considerations are often difficult. We examined the causes of periorbital dermatitis and compared the data of 88 patients from the Department of Dermatology, University Hospital Erlangen to those of the German IVDK (Information Network of the Departments of Dermatology). Between 1999 and 2004, predominant causes of periorbital dermatitis were allergic contact dermatitis (Erlangen 44 %, IVDK 32 %), atopic eczema (Erlangen 25 %, IVDK 14 %), airborne contact dermatitis (Erlangen 10 %, IVDK 2 %) and irritant contact dermatitis (Erlangen 9 %, IVDK 8 %). Less frequent causes for secondary eczematous periocular skin lesions were periorbital rosacea, allergic conjunctivitis or psoriasis vulgaris. Female gender, atopic skin diathesis and age of 40 years and older were identified as risk factors for periocular dermatitis. Common elicitors of periorbital allergic contact dermatitis were leave‐on cosmetic products (face cream, eye shadow) and eye drops with the usual allergens being fragrances, preservatives and drugs. Exact identification of relevant contact allergens and allergen elimination are essential for successful treatment. Calcineurin inhibitors are the first‐line therapy for facial atopic eczema. They may be also effective in periocular eczematous lesions of other origins although they are not approved for such use.     

Contact dermatitis due to topical treatment with garlic in Hong Kong

Contact dermatitis due to garlic is usually due to handling of garlic for cooking. Among the Chinese, garlic is also used as a form of topical medicament. 8 patients developed contact dermatitis after rubbing the cut end of a fresh garlic bulb onto the skin to treat fungal and other infections at the groin, neck, lower limb, hand or face. The distribution and morphology of the lesions were different from the classical form as described in the literature. Repeated open application tests with fresh garlic were all positive and patch tests with garlic extract were all negative. 5 controls tested by repeated open application with fresh garlic juice were also positive and patch tests in 10 controls with garlic extract were also negative. The results confirmed that the contact dermatitis was due to irritation. The patients were treated successfully with topical fluorinated steroid. For prevention, the practice of direct application of fresh garlic onto the skin for treating infections should be discouraged.     

Contact sensitization in patients with chronic venous leg ulcers in Singapore

Contact sensitization rates are high in patients with chronic venous leg ulcers. Allergic contact dermatitis poses a significant hindrance to the healing of the wounds. There are no published studies examining the rate of contact sensitization in Asian patients. Our objective was to determine the rate of contact sensitization in patients with chronic venous leg ulcer in Singapore and the variation in the common allergens based on local practices in comparison with Western countries. 44 patients were patch tested to the National Skin Centre standard series, steroid series, medicaments, topical Chinese medicaments, and to modern wound dressings used. The overall rate of contact sensitization was 61.4%. The common allergen groups were topical antibiotics (18.2%) and topical traditional Chinese medicaments (TTCM) (15.9%). Individually, colophony (11.3%), Saw Hong Choon skin ointment (Kam Bo Med, Hong Kong, Hong Kong) (11.3%), Balsam of Peru (9.1%), and povidone iodine (9.1%) were among the most frequent allergens. The sensitization rate among users of TTCM was notably high (41%). A high rate of contact sensitization was found in our study, similar to previous reports from the West. TTCM play a major role as possible allergens in our patients. In Asian patients, a history of its usage should be elicited, and patch testing should include the commonly used TTCM where possible.     

Contact allergy to food

Contact allergies to foods, spices, and food additives can occur to individuals in the workplace or at home. Seven different reaction types have been described. These include irritant contact dermatitis, allergic contact dermatitis, contact urticaria, protein contact dermatitis, phototoxic contact dermatitis, photo-allergic contact dermatitis, and systemic contact dermatitis. The causes of each of these are reviewed and an approach to the diagnosis and management of contact allergy to foods, spices, and food additives is formulated.