Periorbital dermatitis--a recalcitrant disease: causes and differential diagnoses

Background Periorbital dermatitis is common and frequently recalcitrant to treatment. Due to the exposed and visible location, patients often suffer severely from periorbital dermatitis. Objectives To determine the frequency and causes of periorbital dermatitis including contact sensitizers. Methods We investigated two cohorts of patients (Erlangen and IVDK without Erlangen) between 1999 and 2004. Results The differences between the two cohorts with periorbital dermatitis [Department of Dermatology at University Hospital Erlangen (n = 88) and the German Information Network of Departments of Dermatology (IVDK) collective (n = 2035)] were determined by the MOAHLFA (male, occupational dermatosis, atopic eczema, hand dermatitis, leg dermatitis, facial dermatitis, age ≥ 40 years) index. Statistically significant factors for periocular eczema are female sex, atopic skin diathesis and age ≥ 40 years. In both cohorts allergic contact dermatitis was the main cause of periorbital eczema (Erlangen 44·3%, IVDK 31·6%), followed by periorbital atopic dermatitis (Erlangen 25%, IVDK 14·1%), airborne dermatitis (Erlangen 10·2%, IVDK 1·9%), irritant contact dermatitis (Erlangen 9·1%, IVDK 7·6%), periorbital rosacea (Erlangen 4·5%, IVDK 2·2%), allergic conjunctivitis (Erlangen 2·3%, IVDK included in ‘others’) and psoriasis (Erlangen 2·3%, IVDK included in ‘others’). The most relevant allergens/allergen sources inducing periorbital eczema were consumers’ products (facial cream, eye shadow and ophthalmic therapeutics) (31%), fragrance mix (19%), balsam of Peru (10%), thiomersal (10%) and neomycin sulphate (8%); 12·5% of patients with allergic periocular dermatitis could be exclusively elucidated by testing patients’ own products. Conclusions Our data demonstrate the multiplicity of causes for periorbital eczematous disease manifestation, which requires patch testing of standard trays as well as consumers’ products to elucidate the relevant contact sensitization.     

Contact sensitivity in patients with recalcitrant atopic dermatitis

Patients with atopic dermatitis are usually responsive to conventional treatment such as topical steroids; however, they are sometimes refractory to the treatment. The influence of contact sensitivities on the course of patients with recalcitrant atopic dermatitis is not known. The aim of this study was to investigate whether contact sensitivities affect the course of patients with recalcitrant atopic dermatitis. We evaluated 45 patients with atopic dermatitis who had failed conventional therapy. Patch testing was performed with the Japanese standard series, metal series and/or suspected items. A total of 15 patients had a positive patch test reaction to at least one allergen. The most common allergens were nickel, topical drugs and rubber accelerators. Avoidance of products or food containing allergic substances greatly or partially improved skin symptoms in nine patients. These results suggest that contact allergens and metals may be critical factors causing eczematous lesions in patients with recalcitrant atopic dermatitis.     

Allergic and non-allergic periorbital dermatitis: patch test results of the Information Network of the Departments of Dermatology during a 5-year period

Periorbital dermatitis is common and can be due to the external use of ophthalmic drugs. We evaluated patch test results of the Information Network of the Departments of Dermatology. During a 5-year period (1995-99), of a total 49,256 patch-tested patients, 1053 (2.1%) were eventually diagnosed as allergic periorbital contact dermatitis (APD) and 588 (1.2%) as non-allergic periorbital dermatitis (NAPD). Patient characteristics between APD, NAPD and other cases (OCs) differed with respect to sex (19.7% male in both periorbital groups versus 36.3% in OCs), atopic dermatitis (10.4% in APD versus 60.2% in NAPD versus 16.9% in OCs) and age, APD being substantially more often (68.2%) aged 40 and above than NAPD (52.6%). Several of the top allergens in OCs [such as fragrance mix, Myroxylon pereirae resin (balsam of Peru), lanolin alcohol and potassium dichromate] caused significantly fewer positive test reactions in both periorbital groups. In contrast, thimerosal, phenylmercuric acetate, sodium disulfite, gentamicin sulfate, phenylephrine hydrochloride and benzalkonium chloride tested positively significantly more often in APD but not in NAPD, verifying them as true ophthalmic allergens. Finally, in 42 cases (4%) of APD patients, additional allergens were identified by testing of the patients' own substances (mostly beta-blockers, oxybuprocaine and dexpanthenol), supporting the necessity of testing with ophthalmic drugs as is where individual substances are not readily available.     

Occupational dermatitis in bakers: a clue for atopic contact dermatitis

6 patients are described who developed contact dermatitis after cereal contact on atopic skin for periods of 2 to 20 years. 2 patients were wheat flour patch-test-positive. They had punch biopsies taken for standard histological and immunohistochemical investigation by labeling with monoclonal antibodies, anti-DR and anti-IgE. Sections showed features of contact dermatitis. There were many dendritic cells located perivascularly in the papilla and in the epidermidis, intensely positive for monoclonal anti-IgE antibody. In control atopic subjects, there were a few perivascular IgE positive cells, probably mastocytes. This study shows that there may be a relationship between some allergens and atopic eczema in patients exposed to them in the course of their work. In some cases, there was a true allergic contact dermatitis, seen through the clinical and histological characteristics, and the results of immunohistochemical study.     

Sensitizing potential of triclosan and triclosan-based skin care products in patients with chronic eczema

Triclosan is a lypophilic chlorophenol biocide with broad-spectrum antibacterial and antifungal activity. Triclosan-based topical products have been shown to be tolerated and beneficial in atopic dermatitis. The aim of this study was to evaluate the sensitizing potential of triclosan and triclosan-based creams in patients affected by eczematous dermatitis. Two hundred and seventy-five patients affected by chronic eczema (allergic contact dermatitis, irritant contact dermatitis, atopic eczema, nummular eczema, stasis dermatitis) were patch tested with standard patch test series as well as triclosan and triclosan-based products. Standard patch test series resulted positive in 164 patients (61%), with nickel sulfate, house dust mites, fragrance mix, propolis, thimerosal, myroxylon pereira, potassium dichromate, wool alcohols, and p-phenylenediamine the most common sensitizing haptens. Only two patients developed positive reactions to triclosan (0.7%) and four (1.4%) to triclosan-based products. The present study's results confirm that triclosan is well tolerated and has a very low sensitizing potential even in high-risk patients affected by eczema.     

Hairdressers with dermatitis should always be patch tested regardless of atopy status

Background: Allergic contact dermatitis is common in hairdressers because of their exposure to chemicals used in hair dyes and permanent wave solutions. Atopic individuals are known to have a higher prevalence of leaving the profession due to morbidity associated with hand eczema. Objectives: To assess which chemicals are responsible for allergic contact dermatitis in hairdressers and whether the prevalence is the same according to atopy status. Methods: A total of 729 hairdressers who had been patch tested were retrospectively identified. Allergic reactions to relevant allergens from the extended European baseline series and hairdressing series were analysed against history of atopic eczema. Results: Of the total, 29.9% of patients had a current or past history of atopic eczema. The most frequent positive allergens from the European baseline series were nickel sulfate (32.1%) and p‐phenylenediamine (19.0%) and from the hairdressing series were glyceryl monothioglycolate (21.4%) and ammonium persulfate (10.6%). There was no significant difference between people with or without a history of atopic eczema, except for fragrance mix I and nickel sulfate. Conclusions: We present findings from the largest cohort of hairdressers patch tested from a single centre. It is necessary to patch test hairdressers with dermatitis, regardless of a history of atopy. Strategies to reduce prevalence of allergic contact dermatitis are required.     

Patch testing in children with hand eczema. A 5-year multicentre study in Spain

Background. Hand eczema is common in children, but affected children are seldom patch tested. Relatively few studies have assessed patch testing in the paediatric population, and none has specifically evaluated its use in hand eczema in children. Objectives. The aim of this study was to determine the prevalence of contact allergy in children with hand eczema, and to identify the most frequent allergens and their relevance. Material and methods. We performed a 5‐year retrospective study of children (aged 0–15 years) with hand eczema tested with the Spanish baseline series at the Dermatology Departments of 11 Spanish hospitals. Results. During the study period, 11 729 patients were patch tested, of whom 480 were children. Hand eczema was present in 111 (23.1%) of the children and in 3437 (30.5%) of the adults. Of the children with hand eczema, 46.8% had at least one positive reaction in the patch tests. Current relevance was found for 78% of the allergens detected. The most common allergens were nickel sulfate, methylchloroisothiazolinone/methylisothiazolinone, and fragrance mix I. Allergic contact dermatitis was the most frequent diagnosis (36%), followed by atopic dermatitis. Conclusions. Allergic contact dermatitis was the most usual diagnosis in our series of children with hand eczema. We recommend patch testing of all children with chronic hand eczema, as is already performed in adults.     

Sensitizing agents found in children and adolescents with recalcitrant atopic dermatitis: a cross-sectional study with a pediatric battery

BackgroundAtopic dermatitis is the most common inflammatory skin disease in childhood and has an important impact on quality of life, especially severe cases or those that are recalcitrant to treatments. Sensitization to allergens with the potential for allergic contact dermatitis is a factor associated with cases of recalcitrant atopic dermatitis. Understanding the relationship between atopic dermatitis, allergens, and allergic contact dermatitis is essential. In Brazil, there are no studies on sensitization to allergens found in patch tests with pediatric batteries in patients with atopic dermatitis.ObjectivesTo verify the main sensitizing agents, the prevalence of allergic contact dermatitis and the epidemiological and clinical profile of children and adolescents with atopic dermatitis.MethodsCross-sectional, prospective study in patients between 4 and 18 years of age, with recalcitrant atopic dermatitis, treated at the Sanitary Dermatology Outpatient Clinic (RS). All patients underwent patch tests with a battery of pediatric allergens.ResultsThe prevalence of sensitization and allergic contact dermatitis in the evaluated patients was 37.07% (20/54) and 27.7% (15/54), respectively. The most frequent allergens were: nickel sulfate (16.7%), disperse blue (5.6%), and fragrance mix I (5.6%). Nickel was associated with the female sex (p = 0.019).Study limitationsSample size and selection, absence of a control group.ConclusionsA proportion of patients with recalcitrant atopic dermatitis may be sensitized to different allergens and may even have developed allergic contact dermatitis. Recognizing this context is important in the prevention strategy and management of the disease.     

Anogenitaldermatosen – allergische und irritative Auslösefaktoren Analyse von Daten des IVDK1 und Literaturübersicht

Background: Anogenital dermatoses (AGD) are common and often very distressing. Clinically it is often unclear if allergic contact dermatitis or irritant dermatitis is involved. In order to optimize therapy and prophylaxis, it is essential to identify relevant allergens or irritants. Patients and Methods: Data of the Information Network of Departments of Dermatology (IVDK, data center in Göttingen) collected between 1999 and 2003 were analyzed. The anogenital area was involved in 1 168 patients with suspected allergic contact dermatitis. Clinical variables and patch test results were statistically compared with the remaining IVDK patch test population, the latter standardized for age and sex. Results: Allergic contact dermatitis had been suspected prior to patch testing in 39.5 %, while in 24.6 % this diagnosis was eventually confirmed. Irritant contact dermatitis was diagnosed in 11.8 %. Other diagnoses, included balanitis, lichen sclerosus et atrophicus and herpes genitalis. Positive reactions to cinchocaine (6.6 %), bufexamac (3.5 %) and benzocaine (2.4 %) were observed significantly more often among patients with anogenital dermatitis. Among those in whom co‐factors were considered important (n = 422), wetness (38.4 %), occlusion (30.3 %), mechanical strain (4.7 %) and heat (3.6 %) were mentioned as irritation factors. Conclusion: Because of the significantly higher frequency of sensitization to cinchocaine, benzocaine and bufexamac in patients with anogenital dermatitis, these ingredients should be used only with caution. According to the literature, ingredients of toiletries, cosmetics and contraceptives of any kind seem to cause allergic contact dermatitis rarely although there are several case reports. Comprehensive patch test including the standard series plus major sensitizers such as cinchocaine, benzocaine and bufexamac, and in particular patients' own skin care products, is recommended.     

Contact sensitisation in hand eczema patients–relation to subdiagnosis, severity and quality of life: a multi-centre study

Background: Contact sensitisation has been identified as a factor associated with poor prognosis for patients with hand eczema.
Objectives: To study implications of contact sensitisation with respect to severity, quality of life (QoL) and subdiagnosis of hand eczema.
Methods: The study was performed as a multi-centre, cross-sectional study from 10 European clinics. All patients were patch tested, and severity of hand eczema assessed by Hand Eczema Severity Index. A multi-variate analysis was performed to explore which factors influenced severity, QoL and sick leave.
Results: A total 416 patients were included, and 63% had contact sensitisation to one or more of the tested allergens. More women (66%) than men (51%) were sensitized. No significant association was found between sensitisation to specific allergens, disease severity, QoL or diagnostic subgroups. High age, male sex, atopic eczema and presence of contact sensitisation were independent risk factors for increased severity as measured by Hand Eczema Severity Index. Furthermore, the severity of hand eczema increased by the number of contact sensitisations detected ( P = 0.023). High age and personal history of atopic eczema were independent risk factors for low QoL, as measured by Dermatology Life Quality Index, and atopic eczema as well as allergic contact dermatitis as subdiagnosis was associated with increased sick leave.
Conclusion: Diagnostic subgroups were not found to be related to specific allergens. Contact sensitisation was found to be a risk factor for increased severity of hand eczema, as did high age, male sex and atopic eczema.     

Patch test results in patients with scalp dermatitis: analysis of data of the Information Network of Departments of Dermatology

Background: Contact dermatitis of the scalp may develop primarily due to exposure to cosmetic products or secondarily due to application of topical medicaments on affected skin. Objectives: To illustrate the current spectrum of allergens in scalp dermatitis. Patients/methods: Data of 1320 patients recorded by the Information Network of Departments of Dermatology (IVDK) between 1993 and 2003, who were patch tested to confirm or rule out (secondary) allergic contact dermatitis of the scalp, were analysed. Results: Sensitization to p-phenylenediamine, tolune-2,5-diamine, p-aminophenol, 3-aminophenol, p-aminoazobenzene, cocamidopropyl betaine and pyrogallol was significantly more common than in the remaining IVDK patients. In 690 patients, altogether 4070 patients' own products were patch tested. Medical products, hair tints and bleaches (HTB) and hair-cleansing products together caused nearly 2/3 of positive patch test reactions. Among these categories, HTB showed the highest percentage of positive patch test reactions; 24 of 29 HTB-positive patients had no positive reaction to any of the commercially available allergens. Conclusions: In our subgroup of patients with scalp dermatitis, constituents of hair-colouring products were the most important allergens. As some ingredients of hair dyes are not contained in patch test series, testing of patients' own products is an important part of diagnostic workup, as otherwise sensitizations may be missed.     

Allergic contact dermatitis to phenylephrine eye drops in an infant

Ophthalmic medications used for diagnostic or therapeutic purposes are common causes of allergic contact dermatitis around the eyes. We report a case of periocular allergic contact dermatitis due to tropicamide and phenylephrine eye drops in a 1‐year‐old infant.     

317例斑贴试验结果分析

目的：探讨皮炎,湿疹类皮肤病接触性病因及发生规律。方法：用辨敏牌标准筛选斑贴试验试剂盒对患者做斑贴试验。结果：317例患者中阳性者218例,阳性率68．77％,其中湿疹,皮炎,荨麻疹的阳性率明显高于其他病种,痤疮,丘疹性荨麻疹,唇部色素沉着亦有阳性结果。结论：斑贴试验对皮炎,湿疹类皮肤病有确定的指导,防治意义,对某些不典型的皮肤病,如寻常痤疮,丘疹性荨麻疹,唇部色素沉着等应做斑试,以排除接触过敏的可能。     

Sites of dermatitis in a patch test population: hand dermatitis is associated with polysensitization

Background  Sites of dermatitis in larger series of contact allergic patients are rarely reported. Increased risk of polysensitization has been linked only to stasis dermatitis and leg ulcers. However, a large proportion of polysensitized individuals may have dermatitis in other skin areas.
Objectives  To examine the site of dermatitis at time of first appearance in contact allergic individuals with special focus on the distribution of dermatitis in polysensitized individuals and to examine if widespread dermatitis is more frequent in polysensitized than in single/double-sensitized patients.
Methods  A matched case–control study was carried out including 394 polysensitized and 726 single/double-sensitized patients who responded to a postal questionnaire. All subjects were recruited from a hospital patch test population.
Results  The hands were the most frequent and the anogenital region was the least frequent skin area affected with dermatitis. Dermatitis on the hands/wrists [odds ratio (OR) 1·58], in the armpits (OR 1·56) and on the back (OR 1·91) was positively associated with polysensitization. The hands were the only skin area with dermatitis which maintained the association to polysensitization in two subpopulations consisting of, respectively, individuals with and without atopic eczema. Dermatitis on the scalp was negatively associated with polysensitization (OR 0·66) primarily for individuals without atopic eczema. The dermatitis did not seem to be more widespread in polysensitized compared with single/double-sensitized patients.
Conclusions  Special awareness in patients with hand dermatitis seems justified either to prevent development of multiple contact allergies or to document polysensitization as an aetiological factor.     

过敏性皮肤病患者斑贴试验结果分析及临床意义

目的研究过敏性皮肤病患者斑贴试验结果及临床意义.方法对254例湿疹、56例慢性荨麻疹、28例特应性皮炎患者进行斑贴试验检测.结果三组患者中阳性率较高的致敏原有四种物质相同,分别为硫酸镍、重铬酸甲、卡巴混合物、芳香混合物;特应性皮炎组阳性率(64.29%)明显低于湿疹组(79.92%),慢性荨麻疹(76.79%)与湿疹二组阳性率之间差异无显著性.结论过敏性皮肤病患者阳性率较高的致敏原具有相同性;硫酸镍、重铬酸甲、卡巴混合物、芳香混合物具有较高的致敏性;斑贴试验主要用于检测外源性变应原,特应性皮炎的病因可能以内源性为主;接触性过敏原可以引起接触性荨麻疹;斑贴试验阳性致敏原常是引起面部湿疹、手湿疹的致病因素.     

Allergic contact dermatitis among maintenance and clerical workers in a military population

Contact dermatitis is one of the leading causes of occupational morbidity and absenteeism and has become an intolerable cause of missed workdays and health problems in the Israeli military. The aim of this study was to determine the rate of contact dermatitis in maintenance and clerical workers, the common allergens causing it, and the background of atopy in the subjects in order to design preventive measures. Medical records of all recruits to the Israel Defense Forces from 2000 to 2003 were reviewed for contact dermatitis. The 102 cases found were further assessed for job assignment, atopic background, and allergens. Of the 102 cases, 60 had irritant contact dermatitis and 42 had allergic contact dermatitis, of which 33 (78.6%) were maintenance workers, mainly mechanics. 13 soldiers in the maintenance job category (39%) and 2 soldiers in the clerical group (22.2%) had atopic background. There were 55 positive reactions in patch tests, 25 of them to oil and cooling fluids, with 14.5% attributed to methylchloroisothiazolinone/methylisothiazolinone) (Kathon CG). Atopy was found to be a risk factor for allergic contact dermatitis in our study and should be screened for in job assignment procedures in the military. Oil and greases contain significant allergens, especially their preservatives.     

The aetiology of eyelid dermatitis: a 10-year retrospective analysis

Few studies have examined the aetiology of eyelid dermatitis across broad demographics. The objectives of this study were (i) to compare the diagnoses of patients with isolated eyelid dermatitis to the diagnoses of patients with additional sites of involvement and (ii) to determine the relevant allergens among patients with allergic eyelid dermatitis. A retrospective analysis of 1215 patients patch tested over 10 years was conducted in this study. Compared to patients without eyelid dermatitis, patients with this entity were more often female. Of the 105 patients with eyelid dermatitis, 43.8% had allergic contact dermatitis (ACD), 36.2% seborrhoeic dermatitis, 11.4% other dermatitis/dermatoses, 7.6% irritant contact dermatitis, 3.8% psoriasis, and 2.9% atopic eczema. With isolated eyelid dermatitis, seborrhoeic dermatitis was the most frequent diagnosis (46.3%) followed by ACD (35.2%). Allergens commonly causing allergic eyelid dermatitis consisted of fragrances, metals, neomycin, oleamidopropyl dimethylamine, tosylamide formaldehyde resin, benzalkonium chloride, and other preservatives. When evaluated according to sites of involvement, seborrhoeic dermatitis was diagnosed most often in patients with isolated eyelid dermatitis, but when dermatitis was distributed to facial or other sites, ACD was the most frequent diagnosis. A majority of the causative allergens for eyelid dermatitis are not present on the Food and Drug Administration-approved panels available in the USA.     

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.     

皮炎湿疹类疾病规范化诊断术语专家共识

【摘要】 针对皮炎湿疹类疾病在概念、分类和诊断术语等方面的混乱现状,中华医学会皮肤性病学分会免疫学组、中国医师协会皮肤科医师分会指南制定与规范委员会组织专家按照德尔菲法原则对皮炎湿疹类疾病的诊断现状及存在问题进行讨论,提出7条规范化诊断建议,主要包括：①“皮炎”和“湿疹” 是疾病的类别名称而非具体诊断术语;②临床遇到湿疹性皮损时,应积极寻找其临床特征和/或实验室特点,按照特应性皮炎、接触性皮炎和其他皮炎进行分类诊断;③建议暂时保留“湿疹”这一术语,并只用作以湿疹性皮损为表现但尚不能给出确定诊断的、暂时性和描述性诊断用词。本共识旨在推动皮炎湿疹类疾病诊断术语的规范化、同质化,为更好地进行疾病管理、流行病学研究和开展个体化治疗和预防奠定基础。