Allergic contact dermatitis to topical antibiotics: Epidemiology, responsible allergens, and management

Topical antibiotics are widely used to treat cutaneous, ocular, and otic infections. Allergic contact dermatitis to topical antibiotics is a rare but well-documented side effect, especially in at-risk populations. The purpose of this article is to review the epidemiology, responsible allergens, and management of allergic contact dermatitis to topical antibiotics. LEARNING OBJECTIVE: After completing this learning activity, participants should be able to describe the epidemiology of allergic contact dermatitis related to topical antibiotics; show knowledge of the most common allergenic topical antibiotics; and understand the allergenic cross-reactivity pattern amongst topical antibiotics.     

Phytodermatitis.

BACKGROUND: Most dermatologists can recognize the classic patterns of presentation of plant contact dermatitis; however, few can recognize the offending plants or know the name and chemical structure of the allergens or irritants that they contain. OBJECTIVE: Five basic clinical patterns of phytodermatitis are reviewed: 1) allergic phytodermatitis, 2) photophytodermatitis, 3) irritant contact dermatitis, 4) pharmacologic injury, and 5) mechanical injury. The plants responsible for each pattern are presented by families, according to current scientific taxonomy. The chemical structure of the offending substances is described, and principles of investigation, prevention, and treatment are outlined. CONCLUSIONS: Plant contact dermatitis remains an extremely vast and complex topic. Exotic plants and woods are now present in our gardens and homes. The newfound interest in aromatherapy, phytotherapy, and so-called "natural" therapies is the cause of a tremendous increase in exposure to plant products and extracts. This is responsible for the appearance of atypical patterns of plant contact dermatitis with which the practising dermatologist must become familiar.     

The current status of the weed Parthenium hysterophorus L. as a cause of allergic contact dermatitis

The dissemination of allergenic plants as horticultural introductions, or in the case of the weed Parthenium hysterophorus L. apparently by chance, can have undesirable results. This species of the Compositae family, native to the Caribbean region, has spread widely in India, causing allergic contact dermatitis from its content of sesquiterpene lactones, and has recently appeared in Australia.
The clinical features consist of dermatitis of the exposed skin surfaces from direct contact with the weed, but resembling photo dermatitis. In fact, contact dermatitis from the plant can coexist with light sensitivity. The plant does not show phototoxic activity but may contain an unidentified photo allergen. Since plant hairs and the pollen contain sesquiterpene lactones, they can probably cause air bone contact dermatitis. Attempts to control spread of the plant have so far not been successful.     

Clinically relevant patch test reactions in children--a United States based study

Allergic contact dermatitis in the pediatric population is more common than previously recognized, with recent prevalence estimates of positive patch test reactions in the range of 14-70% of children patch tested. The aim of this study was to confirm the prevalence of clinically relevant allergic contact dermatitis in children at two referral centers and determine the most common contact allergens. We performed a retrospective case series analysis of 65 symptomatic children (35 girls and 30 boys) aged 1-18 years old who were patch tested over a 5-year period for recalcitrant dermatitis. Positive patch test reactions were noted in 54 of the 65 children (prevalence rate of 83%) to 80 different allergens. Fifty children (77%) had positive reactions which were determined to be of "definite" or "probable" current clinical relevance. We conclude that the diagnosis of allergic contact dermatitis to specific relevant allergens is common in children referred for patch testing and that contact allergy should be considered in all children with recalcitrant dermatitis. With this article, we review the literature and present a US based study regarding the clinical relevance of positive patch test reactions in children.     

Clinical evaluation of patients patch tested with plant series: a prospective study

Background:

Plants are ubiquitous in nature and are essential for human life, though some do have detrimental effects. In India, there are various indigenous and foreign plants that are well known to cause dermatitis, Parthenium hysterophorus being the foremost.

Aims of the Study:

To study the clinical features of patients presenting with plant dermatitis and evaluate plant allergen series patch test results.

Materials and Methods:

50 patients with suspected plant dermatitis were evaluated regarding evolution of dermatitis, precipitating factors and contact with various plants. 31 patients (62%) complained of photo sensitivity and 24 (48%) had involvement of sun-exposed areas. Our provisional diagnoses included allergic contact dermatitis in 16, air borne contact dermatitis in 9, phytophotodermatitis in 7, photodermatitis in 6, airborne contact dermatitis to other causes in 4, phytodermatitis in 3. Patients were patch tested with Indian standard series of allergens as well as plant allergen series consisting of common allergenic plants of local flora in and around Manipal and also with plants strongly suspected by the patient. 35 tested positive with maximum positives (26 patients, i.e., 52%) to Parthenium hysterophorus (Compositae).

Results:

The result of patch testing was correlated with the history and clinical examination and relevance established.

Conclusions:

Majority of the patients with clinically suspected plant dermatitis belonged to 3^rd or 4^th decade and Parthenium was the leading plant allergen Sensitization to Leguminosae plants and Hopea ponga, seen in 9 cases, have not been reported earlier in literature.     

Perfil de los pacientes con dermatosis en las manos remitidos a la Unidad de Contacto de un hospital terciario e impacto de las pruebas epicutáneas en el diagnóstico

ObjectiveThis study aimed to define the epidemiological and clinical characteristics of patients referred to a contact dermatitis unit for hand dermatitis.Material and methodsWe retrospectively analyzed patients referred for hand dermatitis to the contact dermatitis unit of the Hospital Germans Trias i Pujol, Barcelona, Spain, between 2004 and 2007.ResultsA total of 96 patients were included. The most common diagnosis was irritant contact dermatitis, followed by allergic contact dermatitis, psoriasis, dyshydrosis, and atopic dermatitis. Standard patch tests were done for all patients and complementary batteries were ordered in 42 (44 %). Patch tests were positive in 59 % of the patients. Positive results were considered of present relevance in 59 %, of past relevance in 6 %, and of unknown relevance in the remaining positive tests. When proposed as the initial diagnosis, allergic contact dermatitis was confirmed in 67 % of the patients. The most frequent clinically relevant allergens were chrome, nickel, rosin, plant allergens, and p-phenylenediamine.ConclusionsHand dermatitis is a frequent presenting complaint in our contact dermatitis unit, with allergic contact dermatitis being the most common. Good correlation was found between presumed diagnosis of allergic contact dermatitis and the finding of clinically relevant allergens.     

Patch testing is a useful investigation in children with eczema

Background. Allergic contact dermatitis in children is less recognized than in adults. However, recently, allergic contact dermatitis has started to attract more interest as a cause of or contributor to eczema in children, and patch testing has been gaining in recognition as a useful diagnostic tool in this group. Objectives. The aim of this analysis was to investigate the results of patch testing of selected children with eczema of various types (mostly atopic dermatitis) attending the Sheffield Children's Hospital, and to assess potential allergens that might elicit allergic contact dermatitis. Patients and methods. We analysed retrospectively the patch test results in 110 children aged between 2 and 18 years, referred to a contact dermatitis clinic between April 2002 and December 2008. We looked at the percentages of relevant positive reactions in boys and girls, by age groups, and recorded the outcome of treatment following patch testing. Results. One or more positive allergic reactions of current or past relevance was found in 48/110 children (44%; 29 females and 19 males). There were 94 allergy‐positive patch test reactions in 110 patients: 81 had a reaction of current or past relevance, 12 had a reaction of unknown relevance, and 1 had reaction that was a cross‐reaction. The commonest allergens with present or past relevance were medicaments, plant allergens, house dust mite, nickel, Amerchol® L101 (a lanolin derivative), and 2‐bromo‐2‐nitropropane‐1,3‐diol. However, finding a positive allergen was not associated with a better clinical outcome. Conclusions. We have shown that patch testing can identify relevant allergens in 44% of children with eczema. The commonest relevant allergens were medicament allergens, plant allergens, house dust mite, nickel, Amerchol® L101, and 2‐bromo‐2‐nitropropane‐1,3‐diol. Patch testing can be performed in children as young as 2 years with the proper preparation.     

Plant dermatitis: asian perspective

Occupational and recreational plant exposure on the skin is fairly common. Plant products and extracts are commonly used and found extensively in the environment. Adverse reactions to plants and their products are also fairly common. However, making the diagnosis of contact dermatitis from plants and plant extracts is not always simple and straightforward. Phytodermatitis refers to inflammation of the skin caused by a plant. The clinical patterns may be allergic phytodermatitis, photophytodermatitis, irritant contact dermatitis, pharmacological injury, and mechanical injury. In this article, we will focus mainly on allergy contact dermatitis from plants or allergic phytodermatitis occurring in Asia.     

Patch test sensitization to Compositae mix, sesquiterpene-lactone mix, Compositae extracts, laurel leaf, Chlorophorin, Mansonone A, and dimethoxydalbergione.

BACKGROUND: Compositae mix and sesquiterpene-lactone (SL) mix are important patch test substances to show allergic contact dermatitis from various Compositae plants. OBJECTIVES: The aims of this study are to calculate the sensitization rates to Compositae mix and SL mix in an occupational dermatology clinic and to describe cases of active sensitization caused by patch testing with Compositae mix and SL mix. METHODS: Conventional patch testing was performed. SL mix (0.1%) and Compositae mix (6% in petrolatum) were tested in a modified European standard series and a plant allergen series. Testing with other appropriate patch test series was also performed. RESULTS: SL mix provoked 8 allergic patch test reactions (0.7%) in 1,076 patients, whereas Compositae mix was positive in 15 of 346 patients (4.2%). Three patients were actively sensitized to Compositae mix and 1 patient to SL mix. One patient was also sensitized to other plant allergens in a series of allergenic plant chemicals, namely to Mansonone A, an ortho-quinone; (R)-3,4-dimethoxydalbergione, a quinone; and Chlorophorin, a hydroxy stilbene. Allergic patch test reactions to laurel leaf were caused by cross-sensitization to SLs. CONCLUSION: Compositae mix seems to be a more important patch test substance than SL mix to detect allergic contact dermatitis to Compositae plants, but patch testing may sensitize. The concentration of the individual components of the Compositae mix should be adjusted so that the mix detects allergic patients but does not sensitize.     

The chemistry of contact allergy: why is a molecule allergenic?

This review concentrates on some specific aspects of the chemistry of allergic contact dermatitis. The way low molecular weight chemicals react with skin proteins to form complete antigens will be discussed and the development of molecular modelling techniques to analyse molecular recognition presented. Subsequently, how knowledge of the chemical structure can be used to estimate the allergenic activity of a molecule will be considered. This aspect includes work with qualitative and quantitative structure-activity relationships (SAR) in the field of contact allergy.     

Occupational allergic contact dermatitis caused by decorative plants

12 cases of occupational allergic contact dermatitis caused by decorative plants were diagnosed in a 14-year period. The patients were middle-aged, and their average exposure time was 13 years. The plant families and plants causing occupational contact dermatitis were Compositae (5 patients: chrysanthemum, elecampane, gerbera, feverfew), Alstroemeriaceae (5 patients, Alstroemeria ), Liliaceae (4 patients; tulip, hyacinth). Amaryllidaceae (2 patients: narcissus) and Caryophyllaceae (2 patients; carnation, cauzeflower). The known chemical allergens causing dermatitis were tuliposide-A and sesquiterepene lactones, such as alantolactones and parthenolide, in the Liliaceae and Compositae families. 7 of the 12 patients were able to continue their work; 5 were not because of severe relapses of skin symptoms. The plant allergen and extract series currently available are of great help in the diagnosis.     

Treatment of dermatitis from parthenin

Composites and some other plants containing sesquiterpene lactones, frequently cause allergic contact dermatitis in man. No treatment is available to control this disease successfully. We have used an amino acid, cysteine, to treat allergic contact dermatitis in guinea pigs sensitized to parthenin, a major sesquiterpene lactone of an allergenic weed, Parthenium hysterophorus L. Cysteine treatment of the allergic reaction induced by parthenin resulted in (a) reduced time of recovery and (b) reduced intensity of the skin reaction.     

Allergic contact dermatitis from ophthalmics: 2007

We previously reviewed allergic contact dermatitis due to ophthalmic drugs and contact lens solutions. Since 1997, an additional 15 allergens have been reported. Here, we provide a review and discussion of these allergens.     

Compositae dermatitis

Compositae dermatitis is an allergic contact dermatitis. The most important allergens in the Compositae family are sesquiterpene lactones (SL), which are present in the oleoresin fraction of leaf, stem, flower and possibly pollen. Compositae dermatitis is most frequently seen in middle-aged and elderly people in patterns reflecting airborne or direct contact with the allergens. The pattern typically starts in summer and disappears in the autumn or winter. Repeated exposure over many years may lead to a chronic and, at times, a disseminated pattern. Seasonal variation does not occur in occupational Compositae dermatitis. In addition to the classically described airborne pattern of face, 'V' of neck, hands and forearms, hand dermatitis is now recognized to be an equally common presentation. This variability of clinical features, and the frequent occurrence of atopic dermatitis and contact allergy to one or more compounds, highlights the need for routine patch testing with sesquiterpene lactone mix 0.1% (Thermal, Hamburg, Germany), combined with aimed patch testing with Compositae plants and extracts. Avoidance of the plants and plant extracts of this large family can be difficult due to its widespread occurrence in flower, herb and vegetable gardens, urban and rural weed population and native vegetation. Importantly, Compositae plant extracts are present in many cosmetics, shampoos, herbal creams and ingested herbal remedies and tonics.     

Occupational contact dermatitis in the pharmaceutical industry

Occupation-induced skin reactions are not infrequently observed in the pharmaceutical industry. Workers may come in contact with irritant substances and also with chemically reactive intermediates or drugs that may be potential sensitizers. The skin lesions can be located at the site of contact, usually the hands, although airborne reactions on exposed and even nonexposed areas (eg, by particles trapped under clothing) are not uncommon. Generalized reactions may occur due to inhalation or transcutaneous absorption. An accidental exposure to a highly allergenic compound may cause a chemical burn, followed by primary sensitization and allergic contact dermatitis. The pharmaceutical contact allergens belong to many different pharmacologic classes. If several cases of contact dermatitis occur in multiple individuals in the same company, then the working conditions are implicated and should be changed to prevent their recurrence. Measures to be taken include dust control, installation of closed filter equipment, and keeping the workers informed about the potential risks associated with the manipulation of the chemicals.     

The detection of clinically relevant contact allergens with a standard screening tray of 28 allergens

Background. A standard method for diagnosing allergic contact dermatitis in the United States is the Thin‐layer Rapid Use Epicutaneous (TRUE) test (TRUE Test?), which consists of three panels containing 20 individual allergens and eight allergen mixes. Previous studies had raised concern regarding the adequacy of the initial two‐panel TRUE Test? system (16 individual allergens and seven allergen mixes) in fully assessing patients with possible allergic contact dermatitis. Objectives. We sought to investigate the effectiveness of the current three‐panel TRUE Test? as the sole diagnostic tool for detecting allergic contact dermatitis. Patients/materials/methods. This study was a retrospective analysis of 2088 patients who underwent patch testing between 1995 and 2010. Study groups were analysed to determine whether positive reactions were to allergens and/or mixes present in the TRUE Test? panels. Results. Of the 2088 patch‐tested patients, 1385 had at least one positive reaction. Among these 1385 patients, 27.6% were fully evaluated by use of only the TRUE Test? series, 49.9% were partially evaluated, and 22.5% did not have any of their allergens detected. On assessment for clinical relevance, similar percentages were observed. Conclusion. In our study, the current TRUE Test? series of 28 allergens would have completely identified allergens in only 27.6% of patients. Broadening the standard panel to include common allergens causing >50% of allergic contact dermatitis cases in a given geographical location and aim testing allergens on the basis of the patient's history will increase the test's sensitivity.     

A murine in vitro model of allergic contact dermatitis to sesquiterpene α-methylene-γ-butyrolactones

Summary The use of a lymphocyte transformation test (LTT) to provide evidence of allergic contact dermatitis was investigated. The haptens studied were alantolactone and isoalantolactone, two moderate allergens from Inula helenium L., a decorative and medicinal plant. Only alantolactone showed a significant response in vivo and in vitro in mice sensitized epicutaneously, without using Freund's complete adjuvant. Isoalantolactone did not show any sensitizing capacity in the murine model studied. The comparison of in vitro lymphocyte proliferation and in vivo allergenic capacity showed a good correlation and clearly demonstrates that, of the two sesquiterpene lactones, alantolactone is the better sensitizer.In memory of Prof. C. Benezra and Dr. R. Fraginals accidentally deceased     

Contact allergy to oxidized d-limonene among dermatitis patients

d -Limonene. obtained as a by-product from the citrus juice industry was introduced on the market as a more environmentally friendly defatting and cleaning agent than the traditionally used organic solvents. Autoxidation of d -limonene readily occurs to give a variety of oxygenated monocyclic terpenes that are strong contact allergens. The aim of the present study was to investigate the prevalence of contact allergy to air exposed d-limonene among dermatitis patients. A fraction consisting of d-limonene hydroperoxides was also tested. Screening with oxidized d-limonene will detect cases of allergic contact dermatitis. Additional cases were detected when testing with the fraction of limonene hydroperoxides. The proportion of positive patch test reactions to oxidized d-limonene was comparable to that seen for several of the allergens within the standard series. An increased UAT of d-limonene containing allergenic oxidation products in industry where high concentrations are used, as well as in domestic exposure, might result in contact sensitization and dermatitis. Patients reacting to d-limonene often reacted to fragrance mix, balsam of Peru and colophony in the standard series.     

Reactions to Aquaphor®: Is Bisabolol the Culprit?

Abstract:  Bisabolol is a sesquiterpene alcohol compound derived from the German chamomile plant, a member of the Compositae family. Only two case reports of adults with allergic contact dermatitis to this chemical exist in the literature, and we describe three more cases of children with recalcitrant atopic dermatitis found to have potential allergic contact dermatitis to bisabolol- a component of the Aquaphor^® emollient they were using to treat their atopic dermatitis. Of note, Compositae dermatitis has been shown to have a higher prevalence in children with atopic dermatitis, so it is important for physicians to be aware of the potential allergens (like bisabolol) in products they are recommending as first line treatments.     

Alstroemeria L. (Peruvian lily).

Alstroemerias are one of the most common plants that cause allergic contact dermatitis in floral workers. This colorful plant has gained great popularity among florists and their patrons. This concise review will help dermatologists to gain familiarity with this plant and show how to diagnose problems that it may cause.