Multicenter study of preservative sensitivity in patients with suspected cosmetic contact dermatitis in Korea

As many new cosmetic products are introduced into the market, attention must be given to contact dermatitis, which is commonly caused by cosmetics. We investigate the prevalence of preservative allergy in 584 patients with suspected cosmetic contact dermatitis at 11 different hospitals. From January 2010 to March 2011, 584 patients at 11 hospital dermatology departments presented with cosmetic contact dermatitis symptoms. These patients were patch-tested for preservative allergens. An irritancy patch test performed on 30 control subjects using allergens of various concentrations showed high irritancy rates. Preservative hypersensitivity was detected in 41.1% of patients. Allergens with the highest positive test rates were benzalkonium chloride (12.1%), thimerosal (9.9%) and methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) (5.5%). Benzalkonium chloride and chlorphenesin had the highest irritancy rate based on an irritancy patch test performed using various concentrations. Seven of 30 normal subjects had a positive irritant patch reading with 0.1% benzalkonium chloride and eight of 30 normal subjects had a positive irritant patch reading at 4 days with 0.5% chlorphenesin in petrolatum. Although benzalkonium chloride was highly positive for skin reactions in our study, most reactions were probably irritation. MCI/MI and thimerosal showed highly positive allergy reactions in our study. The optimum concentration of chlorphenesin to avoid skin reactions is less than 0.5%.     

Post-application occlusion substantially increases the irritant response of the skin to repeated short-term sodium lauryl sulfate (SLS) exposure

Occlusion often, but not always, enhances percutaneous absorption and thus may facilitate skin irritation. Quantitative data about the impact occlusivity may have on minimal irritant stimuli to which the skin is exposed in daily life, and which may lead to chronic irritant contact dermatitis, are however lacking. Irritant stimuli were administered by repeated application of sodium lauryl sulfate (SLS) in an open application procedure. After the open exposure, the skin was either left open or occluded with plastic. Skin irritancy was assessed by means of visual grading and by transepidermal water loss (TEWL) measurements. Post-exposure occlusive treatment markedly enhanced the irritant response. 5 consecutive daily applications produced more irritation, with or without occlusion, than alternate day application. Occlusion may be a relevant factor in the development of irritant contact dermatitis from certain chemicals.     

The tandem repeated irritation test: a new method to assess prevention of irritant combination damage to the skin

The effect of a protective cream was tested in a new tandem repeated irritation test with tandem application of 0.5% sodium lauryl sulphate (SLS) and undiluted toluene. The irritants were applied twice daily for 30 min to the ventral forearms of 20 volunteers. Irritant cutaneous reactions were quantified by a visual score, transepidermal water loss, chromametry and skin capacitance. Concurrent application of SLS/toluene induced stronger reactions than those caused by twice daily application of each irritant on its own. A protective effect of the protective cream was obtained against all treatment combinations and was significant for SLS/SLS (p < or = 0.01) and SLS/ toluene (p < or = 0.05). Our results indicate that the tandem repetitive irritation test has great potential in the evaluation of skin care products to prevent irritant contact dermatitis.     

Pathological findings in cumulative irritation induced by SLS and croton oil in hairless mice

It is known that the pathological features of acute irritant contact dermatitis are specific according to the irritant. However, in chronic irritant contact dermatitis, it is not clear whether specific patterns exist. To investigate whether the specific pathology of acute irritant contact dermatitis is sustained in chronic irritant contact dermatitis, sodium lauryl sulfate (SLS) and croton oil were applied 3x a week for 2 weeks on the dorsal skin of hairless mice using Finn Chambers. The pathologic changes induced by irritants at various concentrations were evaluated using H&E and Luna's staining, as well as immunohistochemistry for 5-bromo-2-deoxyuridine (BrdU), keratin 6 and loricrin. Our results showed that epidermal hyperplasia and inflammatory infiltration were relatively marked in the groups treated with higher concentrations of irritants. These features were more prominent in the 1% croton oil treated group than in the 0.25% SLS treated group. However, lower concentrations of irritants resulted in very similar histological changes, characterized by epidermal hyperplasia with minimal inflammatory infiltration, irrespective of the chemical. Our results suggest that the histological responses to irritants vary with concentration in cumulative irritation, as in acute irritation, but repetitive mild irritation may evoke common histological changes, characterized by epidermal hyperplasia with minimal inflammatory infiltration, irrespective of the chemical used.     

Occupational dermatoses in farmers growing okra (Hibiscus esculentus L.)

By questionnaire survey, 32 out of 52 workers (61.5%) reported previous or current skin diseases from okra cultivation. The sites of skin lesions were mainly the arms, fingers and fingertips. Positive patch test reactions with preparations of okra leaves or immature pods in 111 workers, compared to 63 control subjects, were significantly higher in okra workers than in controls (p less than 0.01), ranging from 9.8 to 30.0%. 37 out of 111 workers (33.3%) were diagnosed as having allergic contact dermatitis (n = 17; 15.3%) and irritant contact dermatitis (n = 18; 16.2%) from okra cultivation.     

Influence of tumour necrosis factor‐α polymorphism −308 and atopy on irritant contact dermatitis in healthcare workers*

Background. Chronic irritant hand dermatitis is an issue for healthcare workers and may negatively impact infection control. Objectives. We examined the effects of a G to A transition at position ?308 on the tumour necrosis factor‐α (TNF‐α) gene on chronically damaged skin of healthcare workers during exposure and recovery from repetitive hand hygiene, after intensive treatment, and on the irritant response in normal skin. Patients/Materials/Methods. In 68 healthcare workers with irritant hand dermatitis, we genotyped TNF‐α?308 and measured the epidermal response via quantitative digital imaging, erythema, dryness, and barrier integrity. Results. Excess hand erythema decreased with hand hygiene exposure and increased during time off for AA/GA genotypes, but had opposite effects for GG. AA/GA had smaller reductions in dryness with lotion treatment and larger reductions in excess erythema than GG. The atopic diathesis and heightened neurosensory irritation resulting from water and lactic acid significantly influenced the responses. Repeated exposure to water and sodium lauryl sulfate (0.05, 0.1%) produced higher erythema in normal skin for AA/GA than for GG. Conclusions. This study provides evidence that the TNF‐α polymorphism at ?308 and an atopic history impact the severity of irritation and recovery from exposure and response to treatment for common hand skin products in both chronic irritant hand dermatitis and normal skin.     

Reduced skin threshold to irritation in the presence of allergic contact dermatitis in the guinea pig

The skin is more susceptible to irritation when an active eczematous process is present. This reduced threshold to irritation occurs in skin distant from the site of the eczematous skin. Data is presented to demonstrate the appearance of irritant dermatitis to lower concentrations of sodium lauryl sulfate during the presence of an allergic contact dermatitis in the guinea pig.     

Dermatitis in bulb growers

A damaged skin forms a health hazard in flower-bulb growers as it enables higher permeation rates For pesticides than normal skin. Therefore, an investigation was performed into the skin condition of 103 bulb growers and 49 controls. Contact dermatitis of the hands was of the same order (11 and 10%) in both groups. However, minor signs of dermatitis were seen more often in bulb growers (30 versus 8%, p <0.05). Most growers had contact with narcissus sap during the investigation. This irritant sap, as well as many other skin contacts with irritants such as hyacinth dust and pesticides, seemed to be responsible for many skin complaints. Contact serialization was suspected in 19 growers and 3 controls. Patch tests showed that contact sensitization existed to pesticides in probably 10, and to flower-bulb extracts in 4 growers. Reactions to propachlor were not regarded as very reliable as the test concentration seemed to be marginally irritant. There were only a few allergic reactions to narcissus (3) and tulip (2) and none to hyacinth. This investigation showed that minor irritant contact dermatitis was frequent in bulb growers, and indicated that contact sensitization to pesticides and bulbs seemed to be a less frequent but important cause of dermatitis.     

Arterio-venous shunt dermatitis in chronic renal failure patients on maintenance haemodialysis

Seven (8%) of 88 patients in chronic renal failure on chronic haemodialysis had arterio-venous (A-V) shunt dermatitis. All were cumulative insult irritant contact dermatitis from soaps, disinfectants and alcohol used for skin cleansing during haemodialysis. None of the five patients with dermatitis who were patch tested had positive responses. The mean time on haemodialysis in those patients with A-V shunt dermatitis (4 years) was longer than in those patients without dermatitis (3 years). No patient with dermatitis had a history of atopy whereas its prevalence was 19% in patients without dermatitis. A-V shunt dermatitis was commoner in patients with pruritus, a common problem in patients in chronic renal failure requiring haemodialysis (29% in patients with pruritus vs. 17% in patients without pruritus). Four patients with A-V shunt dermatitis responded to treatment with mild topical steroids and substitution of normal saline for skin cleansing prior to haemodialysis.     

亚临床皮肤刺激后三种生理参数的变化

目的 探讨经表皮失水(TEWL)、皮肤电容量(CAP)、皮肤表面pH值参数在亚临床刺激性皮炎诊断中应用的可能性.方法 通过1%十二烷基硫酸钠(SLS)开放性斑贴、10次胶带粘贴及0.75最小红斑量UVB照射三种不同的刺激方法,对30名健康女性受试者的前臂屈侧进行处理,共5 d.每天刺激之前进行临床评估.试验第0.6,7,8天进行TEWL、CAP及皮肤表面pH值检测.结果 所有受试者8天内临床评分均为0分;SLS刺激后第6,7,8天TEWL值分别为3.17±3.07(g/m2h)、3.32±2.84(g/m2h)、3.22±2.36(g/m2h),较基础值0.40±1.35(g/m2h)升高,差异均有统计学意义(均为P=0.00).SIS刺激后第6,7,8天CAP值较基础值下降,皮肤表面pH值较基础值升高,与基础值间差异均有统计学意义(P<0.05).胶带粘贴后第6,7,8天TEWL值分别为2.54 ±1.85(g/m2h)、2.40±2.16(g/m2h)、2.17±1.99(g/m2h),较基础值0.11±1.10(g/m2h)升高,差异均有统计学意义(均为P=0.00);胶带粘贴后第8天,皮肤表面pH值较基础值升高,差异有统计学意义(P=0.00);CAP无明显变化.0.75 MED UVB照射后各生物物理参数均无明显变化.结论三种生物物理参数可以被用于亚临床性刺激性接触性皮炎的检测.不同参数对不同的刺激方法检测能力不同.     

Faecal enzymes: in vivo human skin irritation

Digestive enzymes in faeces have been reported to posses skin irritation potential. The present study was designed to investigate the in vivo irritant potentials of faecal concentrations of proteolytic and lipolytic digestive enzymes in bile salt mixtures. In a 21-day cumulative irritation assay, clinical evaluation and noninvasive bioengineering techniques were used. 5 days occlusive exposure to phosphate buffer (pH = 8) caused no visual skin damage but reflectance spectroscopy demonstrated significant vasodilation ( p < 0.01) and increases in transepidermal water loss (TEWL) and skin pH were also observed ( p < 0.01). These increases were still present at days 12 and 19. Occlusive exposure to physiologic concentrations of faecal enzymes resulted in significant visual and objective scores at day 5, 12, and 19, with increased readings as a function of exposure time ( p < 0.01). The enzyme mixture containing lipase caused delayed onset of skin erythema and epidermal barrier disruption compared to elastase and chymotrypsin containing solutions. Prolonged occlusive exposure to digestive enzymes in faecal concentrations caused severe skin erythema and epidermal barrier disruption in a human model, suggesting a possible etiologic role of digestive enzymes in perianal, circumstomal or diaper dermatitis.     

Severe contact dermatitis as a result of an antiseptic bath oil

Siblings aged 7 and 5 years developed extensive truncal and flexural inflammation and desquamation unresponsive to standard eczema therapy. After delays in diagnosis, subsequent history revealed prior use of an antiseptic bath oil in a much stronger concentration than recommended. The case illustrates the severe irritant contact dermatitis that can arise following inadequate dilution of antiseptic bath oils, presumably as a result of skin contact with benzalkonium chloride and triclosan. Features that may direct attention to such irritant dermatitis are flexural predominance with superficial desquamation and rapid improvement after avoidance of exposure to the antiseptic solution.     

Systemic quinine photosensitivity

A 72-year-old woman developed a photodistributed skin eruption while taking quinine hydrochloride (250 mg) once or twice weekly for recumbency cramps. The histopathology showed an eczematous reaction. Phototesting after quinine therapy had been discontinued for one month revealed normal erythema thresholds for ultraviolet (UV) light in the A range (17 J/cm2) and UV light in the B range (20 mJ/cm2). A second phototest after a ten-day period of reexposure to quinine hydrochloride (250 mg daily) showed a drastically lowered threshold for UV light in the A range (less than 1.0 J/cm2), while the test for UV light in the B range was unchanged. The patient's dermatitis also exacerbated with pronounced itching. The histopathologic results from a positive test site were similar to those of her eczematous lesions. We believe this to be the first documented case of systemic quinine photosensitivity. The clinical picture, the results of the phototests, and the histopathology suggest a photoallergic mechanism.     

Moisturizers prevent irritant dermatitis.

The purpose of this study was to investigate the ability of eight different moisturizers to prevent irritant dermatitis. Twelve healthy female students washed the outer aspect of their upper arms with a liquid detergent for one minute twice a day for one week. Seven skin creams and one skin oil were applied to 3 x 7 cm areas of the left upper arm just after each washing, while the right upper arm was left untreated. Transepidermal water loss (TEWL) (mean) increased from 7.1 to 9.3 g/m2/h (p less than 0.001) and laser-Doppler flowmetry (LDF) value (mean) decreased from 11.8 to 10.8 arbitrary units (N.S.) in the left upper arm, but there was no statistical difference between the eight moisturizers. During the second week of the study, the test subjects did not continue washing their arms. Eight areas (3 x 7 cm) of the right upper arm were treated with the moisturizers twice a day. The mean TEWL value decreased from 20.3 to 8.6 (p less than 0.0011) over 7 days, but there were no significant differences between the individual moisturizers. The laser-Doppler values showed the same trend as the TEWL values. In conclusion, regular use of emollients prevented irritant dermatitis from a detergent.     

Propylene glycol dermatitis: re-evaluation of an old problem

Evaluation of dermatitis associated with propylene glycol application or ingestion remains a challenge. The research dealing with skin reactions to propylene glycol is revisited and new aspects for future research are outlined. Based on literature review and our own observations, we propose classifying skin reactions to propylene glycol into 4 mechanisms: (a) irritant contact dermatitis, (b) allergic contact dermatitis, (c) non-immunologic contact urticaria, and (d) subjective or sensory irritation. This concept allows a partial explanation of effects observed by different authors. Despite attempts to define objective criteria, biologically, histopathologically, or clinically, the distinction between irritant and allergic reactions remains unclear. Furthermore, the irritation threshold of propylene glycol, and likewise the optimal standard concentration in patch tests, is subjudice. Future studies on propylene glycol dermatitis should include repeated patch tests with serial dose dilutions, repeated open application tests/pro vocative use tests, oral challenge tests, and biopsies for a more complete evaluation of mechanisms and clinical significance.     

The irritancy of metalworking fluids: a laser Doppler flowmetry study

Irritant contact dermatitis is common in metalworkers exposed to metalworking fluids (MWF). The irritancy of 3 commercially available water-based cutting fluids in maximal user's concentration and 2 neat oils was investigated in 23 healthy volunteers. Additionally, the irritancy of some groups of components of the cutting fluids was studied. After Sellotape stripping, repeated patch tests were performed over 5 days and evaluated by a visual score (VS) and by laser Doppler flowmetry (LDF). In general, the MWF caused marginal skin irritation. In a comparison of the MWF and water, the cutting fluids were ranked higher in irritancy than the neat oils, but the effect of only one cutting fluid could be distinguished from that of water. The components of the cutting fluids also caused no strong reactions. The LDF response showed that one emulsifier was more irritant than water and according to the VS, one corrosion inhibitor was the most irritant. The correlation coefficient between the VS and the LDF response was probably diminished by a strong adverse reaction to the fixing tape in many volunteers. From this experiment, it was concluded that MWF are generally only mildly irritant when used in proper concentrations. However, orthoergic contact dermatitis often develops as a result of repeated and cumulative subclinical insults, in which MWF, especially water-based, play a crucial role because exposure at work is often extensive.     

Allergic and irritant contact dermatitis to calcipotriol.

Calcipotriol (Daivonex R; Leo Pharmaceuticals, Zurich, Switzerland) may cause irritation of the skin, whereas allergic reactions are less common. In the present study we describe two patients with different types of reaction patterns, one presenting as an allergic, the other as an irritant contact dermatitis. Irritative skin reactions were observed only at higher testings doses, in contrast to the allergic type of reaction, which occurred at a lower testing dose. The present observation suggests, that a batch of different testing doses, including lower testing doses may help to differentiate between an allergic type of contact dermatitis and an irritant type of reaction after treatment with calcipotriol.     

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.     

Factors predisposing to cutaneous irritation

In experimental skin toxicology, as well as in clinical practice, considerable interindividual variation in the susceptibility to irritant dermatitis is noted when irritant doses are low. Cutaneous sensitivity and hypersensitivity are not determined by a single known feature but are multifactorial. Previous atopic dermatitis may predispose to irritant dermatitis. Susceptibility to irritation seems to be influenced by age, race, and genetic background, whereas sex-related differences do not seem to exist. Of biophysical skin baseline features, skin-surface pH was correlated with the severity of experimentally induced irritant dermatitis, but baseline transepidermal water loss, water-holding capacity, stratum corneum turnover time, and sebum content were not.     

Barrier recovery and influence of irritant stimuli in skin treated with a moisturizing cream

Moisturizers are used daily by many people to alleviate symptoms of clinically and subjectively dry skin. Recent studies suggest that certain ingredients in creams may accelerate the recovery of a disrupted barrier and decrease the skin susceptibility to irritant stimuli. In the present single-blind study, a moisturizing cream was tested for its influence both on barrier recovery in surfuctant-damaged skin and on the susceptibility of normal skin to exposure to the irritant sodium lauryl sulphate (SLS). Parameters measured were transepidermal water loss (TEWL) and skin corneometer values, indicating degree of hydration. Treatment of surfactant-damaged skin with the test cream for 14 days promoted barrier recovery, as observed as a decrease in TEWL. Skin corneometer values also normalized more rapidly during the treatment. In normal skin, use or the test cream significantly reduced TFWL after 14 days of treatment, and irritant reactions to SLS were, significantly decreased. Skin corneometer values increased after only 1 application and remained elevated after 14 days. In conclusion, the accelerated rate of recovery of surfactant-damaged skin and the lower degree of SLS-induced irritation in normal skin treated with the test cream may be of clinical relevance in attempts to reduce contact dermatitis due to irritant stimuli.