Patch testing in Israeli children with suspected allergic contact dermatitis: A retrospective study and literature review

Background/objectives

Childhood allergic contact dermatitis is recognized as a significant clinical problem. The objective was to evaluate the rate of positive patch tests in Israeli children with clinically suspected allergic contact dermatitis, identify possible sex and age differences, compare results with those in Israeli adults, and review pediatric studies in the literature.

Methods

The study sample included 343 children and adolescents (197 female, 146 male; 1‐18 years of age, mean age 11.8 years) with clinically suspected allergic contact dermatitis who underwent patch testing with a standard pediatric series of 23 allergens at a tertiary medical center from 1999 to 2012. Data on clinical characteristics and test results were collected retrospectively from the medical files.

Results

Ninety‐eight subjects (28.6%) (75 girls [38.1%], 23 boys [15.8%]) had at least one positive reaction. The most frequent reactions were to nickel sulfate, followed by potassium dichromate and cobalt chloride. Nickel sulfate sensitivity was more common in girls, especially those younger than 3 years and older than 12 years. The prevalence of contact sensitization was similar in subjects with and without atopic dermatitis (50% and 51%, respectively).

Conclusion

Nickel is the most common allergen in Israeli children, especially girls. Patch testing should be performed in children with clinically suspected allergic contact dermatitis regardless of atopic background.     

A retrospective study of 2585 patients patch tested with the European standard series in Hong Kong (1995-99)

Background Data on patch test findings in Hong Kong are scarce, with the last survey performed more than 10 years ago. A retrospective analysis of results from all patch tests performed on patients with suspected allergic contact dermatitis from January 1995 to December 1999 in the Social Hygiene Service, which provides a public dermatology service in Hong Kong, was undertaken. We aimed to explore the demographic data associated with positive reactions and the profile of contact sensitizing allergens in Hong Kong. Methods A total of 2585 patients were patch tested with the European standard series during the period. Most were Chinese, with a female‐to‐male ratio of 3 : 2. Results One or more positive responses were noted in 1415 patients (54.7%). The most common allergen was nickel sulfate (24.4%), followed by fragrance mix (13.7%), cobalt chloride (8.7%), p‐phenylenediamine (6.0%), and balsam of Peru (5.7%). Nickel sensitivity was more common in female patients, and dichromate sensitivity was more common in male patients (P < 0.001). Female gender, an age of 40 years or below, truncal and upper limb involvement, absence of lower limb involvement, and a positive atopy history were significant risk factors for nickel sensitivity. Conclusions This study provides a profile of allergens responsible for allergic contact dermatitis in the public dermatology service in Hong Kong. A prospective study, using a larger panel of allergens, involving patients from both the private and public sectors, would provide a more comprehensive profile of contact allergens in Hong Kong and contribute to the establishment of a local standard series.     

155例眼睑皮炎患者斑贴试验结果分析

目的：明确眼睑皮炎的常见变应原。方法：回顾分析我院皮肤科2018年155例眼睑皮炎患者斑贴试验资料。结果：155例眼睑皮炎患者中85例斑贴试验阳性, 总阳性率为54.8%。其中对1项过敏原反应阳性者27例（31.8%）,2项过敏原阳性者19例（22.4%）,3项过敏原阳性者14例（16.5%）,4项及以上过敏原阳性者25例（29.4%）。阳性率较高的前3位过敏原依次是：硫酸镍（24例,9.4%）,甲基异噻唑啉酮（24例,9.4%）,纺织染料混合物（14例,5.5%）。＜20岁,20～39,40～59,≥60岁患者斑贴试验阳性率分别为37.5%,54.2%,65.0%,18.2%,不同年龄组阳性率结果具有统计学意义(χ2=8.483,P＜0.05）。结论：甲基异噻唑啉酮、硫酸镍、纺织染料混合物是眼睑皮炎患者最常见的变应原,变应原阳性率的高低与患者的年龄有一定关联。     

Nickel contact hypersensitivity in children

Nickel allergic contact dermatitis is the most prevalent allergy in North America, with an incidence of 14.3%. It is on the rise from 10 years ago, when the incidence was 10%. This has been presumed to represent an increased exposure to nickel in the environment-especially in costume jewelry and belt buckles. We examined a group of 30 pediatric patients who had either a personal history of umbilical or wrist dermatitis, or a family history of nickel allergic contact dermatitis. All of these patients had a positive patch test to nickel sulfate 5%. Moreover, 50% of patients had an id reaction; all of these patients had positive patch tests that were papular in nature, similar to their papular id reaction. We posit that the presence of a positive family history may be a positive predictor of nickel allergic contact dermatitis, requiring nickel avoidance, especially in atopic children. Based on the high level of positive reactions in patients with umbilical dermatitis and an id reaction, patch testing to nickel in these patients is most likely to yield a useful result. Knowledge of reactivity to nickel would then allow parents and patients to initiate nickel avoidance earlier in life.     

Epidemiology of nickel allergy

In 2400 consecutive patients at 8 clinics in 5 countries, nickel hypersensitivity was found in 176 cases (7.3%), 19 male (2.1%) and 157 female (10.5%). The incidence ranged from 15 to 38 cases in 300 patients of every department (5.0% Sofia to 12.7% Erfurt). 60.6% of the nickel positives were schoolgirls or younger than 25 years. The exposure time was 3 years, in 49% 1 year or shorter. Most cases (75%) are not occupationally acquired, but due to costume jewelry (31.8%), wrist watches (23.3%), metal clothing buckles (3.4%) including jeans buttons. Job dependent nickel dermatitis is often (36/51 cases) linked with wet work. Atopic dermatitis was found in 8.3% of female nickel allergy. Nickel positivity without a dermatitis history was seen in 9/176 cases (5%). Nickel allergy will become a sex-indifferent phenomenon in Europe, because of the changing customs of adornment.     

Allergic contact dermatitis to metal allergens in Iran

Background Metallic allergens such as nickel are among the most common causes of allergic contact dermatitis (ACD), but frequencies of contact dermatitis to these allergens may vary in different areas. Objectives This study aimed to determine the frequencies of ACD caused by three common metallic allergens: nickel sulfate; potassium dichromate; and cobalt chloride. Methods Data for 1137 patients with clinical diagnoses of contact dermatitis and/or atopic dermatitis evaluated by patch testing in Iran during a 5‐year period were retrospectively studied to establish the frequencies of hypersensitivity to these metallic allergens. Results A total of 313 patients (27.5%) gave positive patch test results for at least one metallic allergen. Allergy to nickel (229 cases, 20.0%) was the most commonly observed, followed by allergy to cobalt (90 cases, 8.0%) and allergy to chromium (70 cases, 6.2%). Nickel allergy was significantly more frequent in females and in subjects aged <40 years, whereas chromium hypersensitivity was more common in males and in subjects aged >40 years. Sensitivity to nickel or chromium was a risk factor for cobalt allergy. Conclusions Nickel was most commonly identified as a metallic allergen in Iran and tended to affect women aged <40 years. Regulations pertaining to nickel release may decrease the frequency of nickel hypersensitivity in Iran.     

Nickel sensitivity: Relationship between history and patch test reaction

The prevalence of nickel sensitivity in 415 young adults was examined by patch testing with nickel sulphate 5% in pet. Before testing the persons filled in a questionnaire about personal or family history of atopy and skin reactions after metal contacts. Nickel sensitivity was found in 2.8% of males and 9.8% of females; 13 out of 28 persons with a history of metal contact dermatitis had negative patch test reactions to nickel; eight out of 23 persons with positive patch test reactions to nickel had never experienced skin reactions from metal contacts. These findings indicate that nickel sensitivity cannot be reliably predicted from pretest historical information.     

The trend of nickel allergy from a Scottish tertiary referral centre

The aims of this study were to analyze the change in trend of allergic contact dermatitis (ACD) from nickel in a single tertiary referral centre. In 1982 and 1997, 800 and 860 patients were patch tested, respectively. The frequency of positive reactions to nickel from our centre was 16% in 1982 and 22% in 1997. In both years, the vast majority of patients developed the eruption below 30 years of age. However, the commonest age of onset in 1982 was in the 11-20 year age group, while in 1997, this was 1 decade later, in the 21-30 year age group. In 1997, we noted a much higher female preponderance (F:M=13:1) than in 1982 (F:M=6:1). There was no change in male prevalence but a slight increase in female prevalence in 1997. The rate of atopy in patients with nickel ACD showed an increase from 23% in 1982 to 33% in 1997. Nickel was thought to be a contributory factor in causing occupational dermatitis in 27% of patients in 1982 and 24% patients in 1997. Of these, hairdressing in 1982 and nursing in 1997 were the commonest occupations. In 1982 and 1997, respectively, 40 (5%) and 37 (4%) patients were positive to nickel alone, while 89 (11%) and 150 (18%) patients showed positive reactions to other allergens in addition to nickel. In both the years, the hands were the main sites of involvement. However, in 1997 there was an increase in the number of patients presenting with face and neck involvement.     

Influence of dietary factors,age and nickel contact dermatitis on nickel excretion

Background. Nickel is a frequently detected cause of allergic contact dermatitis. Ingestion of nickel may lead to flares of nickel contact dermatitis. Methods. We examined nickel excretion in the urine of 164 female patients with and without nickel contact dermatitis. The associations between age, atopic dermatitis, nickel contact dermatitis and nickel exposure through nutrition (e.g. dietary supplements) and by patch tests were investigated prospectively. Nickel was measured with atomic absorption spectrometry with two different standardized methods. Results. A nickel detection limit of 0.2 µg/l was exceeded by all samples. The 95th percentiles of urine nickel concentration were 3.77 µg/l (age 18–30 years) and 3.98 µg/l (age 31–46 years). Bivariate analyses pointed to significantly increased nickel excretion with increasing age, ingestion of dietary supplements, drinking of stagnant tap water, and consumption of nickel‐rich food. In the multivariate analysis, age and dietary supplements remained significant predictors of high nickel excretion. A non‐significant increase in the median concentration of nickel was observed after the administration of conventional nickel patch tests. Patients with atopic eczema showed urine nickel concentrations similar to those in non‐atopic controls. Conclusions. The 95th percentile of nickel excretion in our study population markedly exceeded the actual reference value of 3 µg/l. Age and consumption of dietary supplements are the most important predictors. The use of stagnant tap water and consumption of nickel‐rich food contribute to the total load. These factors should be explicitly mentioned when allergic patients on a low‐nickel diet are counselled. In contrast, existing nickel contact sensitization was not more frequent in subjects with higher nickel excretion. Nickel patch testing may cause transient minor systemic nickel exposure. The findings of this study extend our understanding and management of factors associated with nickel allergy.     

Epicutaneous patch test reactions in atopic dermatitis patients

During the 1998-2003 period, patch testing was carried out in 65 atopic dermatitis patients, 20 (31%) male and 45 (69%) female, mean age 34.7 (range 6-77) years. Twenty-six (40%) patients, 7 (27%) male and 19 (73%) female, showed positive reaction to one or more allergens. Allergic reactions were more common in women. The most common allergens were nickel (33.3%), cobalt (11.1%), fragrance mix (11.1%), white mercury precipitate (8.4%), and others (36.1%). There was a significant association between nickel allergy and cobalt allergy. It is concluded that contact hypersensitivity is not rare in patients with atopic dermatitis.     

Allergic contact dermatitis in children

The authors report a study of allergic contact dermatitis in 329 Portuguese children of 14 years or younger. 170 children (64 male and 106 female) reacted to 1 or more allergens. Most of these were in the 11-14 years group. The main allergens were nickel, thimerosal, cobalt, mercury, fragrance-mix and potassium dichromate. Nickel reactivity predominated in females over the whole group, but a greater number of males younger than 5 years reacted to nickel. The number of positive reactions increased with age, but this was not accompained by an increase in the % of relevant tests. 12 children, all of them 13 or 14 years-old, had an occupational allergic contact dermatitis.     

Patch test results in children and adolescents. Study from the Santa Casa de Belo Horizonte Dermatology Clinic,Brazil, from 2003 to 2010

BACKGROUND

Patch testing is an efficient method to identify the allergen responsible for allergic contact dermatitis.

OBJECTIVE

To evaluate the results of patch tests in children and adolescents comparing these two age groups'' results.

METHODS

Cross-sectional study to assess patch test results of 125 children and adolescents aged 1-19 years, with suspected allergic contact dermatitis, in a dermatology clinic in Brazil. Two Brazilian standardized series were used.

RESULTS

Seventy four (59.2%) patients had "at least one positive reaction" to the patch test. Among these positive tests, 77.0% were deemed relevant. The most frequent allergens were nickel (36.8%), thimerosal (18.4%), tosylamide formaldehyde resin (6.8%), neomycin (6.4%), cobalt (4.0%) and fragrance mix I (4.0%). The most frequent positive tests came from adolescents (p=0.0014) and females (p=0.0002). There was no relevant statistical difference concerning contact sensitizations among patients with or without atopic history. However, there were significant differences regarding sensitization to nickel (p=0.029) and thimerosal (p=0.042) between the two age groups under study, while adolescents were the most affected.

CONCLUSION

Nickel and fragrances were the only positive (and relevant) allergens in children. Nickel and tosylamide formaldehyde resin were the most frequent and relevant allergens among adolescents.     

Nickel-elicited systemic contact dermatitis

20 patients with systemic contact dermatitis due to nickel are described. Of these patients, 15 were female and 5 were male. Their mean age was 24.8 years (16-51 years). All had experienced contact dermatitis in the umbilical area due to continual contact with metal belt-buckles or buttons. Then, with long- or short-term aggravation of such periumbilical dermatitis, commonly in summer, lesions spread to other sites such as the side of the neck, the flexures of the extremities, etc. All patients showed a positive patch test to nickel sulphate (2.5% in petrolatum) and the dimethylglyoxime test demonstrated the presence of free nickel on metal buttons or belt-buckles. Punch biopsies performed in 7 patients showed subacute dermatitis. After avoidance of continual exposure to objects containing nickel and foods rich in nickel, as well as treatment with oral antihistamines and topical corticosteroids, all patients improved or cleared. It has been reported that nickel can cause systemic contact dermatitis by some internal systemic route, such as oral intake, transfusion, inhalation, implantation of metal medical devices, etc. In our patients, we found that continual local skin contact could also elicit systemic contact dermatitis.     

Fluctuations in the prevalence of nickel and cobalt allergy in eczema patients patch tested after implementation of the nickel regulation in Denmark

Background. A recent Danish study showed that the prevalence of nickel allergy decreased among young female patients and increased among older female patients with dermatitis patch tested between 1985 and 2007 at Gentofte Hospital, Denmark. The prevalence of cobalt allergy remained unchanged. Objectives. To examine fluctuations in the prevalence of nickel and cobalt allergy after implementation of the nickel regulation, by analysing patch test results from male and female patients with dermatitis tested between 1992 and 2009 at Odense University Hospital, Denmark. Methods. A retrospective analysis of patch test data was performed (female, n = 5821; male, n = 3317). Comparisons were made using the chi‐square test for trend. Logistic regression analyses were used to test for associations. Results. The prevalence of nickel allergy decreased significantly among the 2–30‐year‐old female patients, from 29.8% in 1992–1997 to 19.6% in 2004–2009 (p < 0.001), whereas it increased significantly, from 6.9% in 1992–1997 to 11.1% in 2004–2009 (p = 0.04), among the >60‐year‐old female patients. The overall prevalence of cobalt allergy increased significantly, from 3.7% in 1992–1997 to 5.1% in 2004–2009 (p = 0.03). The overall prevalence of nickel and cobalt allergy among male patients during the test period was 5.2% and 2.2%, respectively, and no significant change across the test years was detected. Conclusions. The prevalence of nickel allergy decreased among young female patients and increased among older female patients with dermatitis, probably because of a cohort effect. The overall prevalence of cobalt allergy increased from 1992 to 2009. No significant trend in the prevalence of nickel and cobalt allergy among male patients was found.     

Patch testing with nickel sulfate: comparison between 2 nickel sulfate preparations and 2 different test sites on the back

Among patients routinely undergoing patch testing for suspected allergic contact dermatitis (ACD), nickel is the most frequently sensitizing hapten, with a clear predominance in the female population. However, some patients who report the appearance of dermatitis upon exposure to metal objects show negative patch test results to a nickel sulfate 5% pet. application. In some cases, a positive response to nickel can be observed simply by repeating the patch test. The objective of our study was to assess if, during routine patch testing, positive responses to nickel sulfate are missed owing to contingent problems, referring to application site, patch test execution or variations in skin reactivity. To this end, we applied 2 different patch test materials containing nickel sulfate 5% pet. to 3040 consecutive patients, undergoing patch testing for suspected allergic contact dermatitis, during the same session. The rôle of the test site was also investigated by applying the preparation on 2 different sites of the back in 30 patients. Of the whole, 612 patients (20%) showed positive patch test responses. The 2 nickel materials were almost equivalent: 78% of nickel-sensitive patients had positive reactions to both, whereas 11% showed a positive response to 1 preparation alone. No variations in patch test responses in relation to application site were observed. Our data show that false-negative patch test responses to nickel are frequent. The use of 2 different preparations during the same patch test session increases the response rate by 10%.     

Retrospective survey of patch testing at department of dermatology and venerology, zagreb university hospital center in zagreb, croatia

Epicutaneous (patch) test is a standard test to confirm contact allergy. During a six-year period (1998-2003), contact allergic dermatitis was diagnosed in 4132 (65%) of 6341 patients using standard patch test with a Croatian series of allergens according to the International Contact Dermatitis Research Group (ICDRG). The most common clinical diagnoses related to contact allergy (male; female) were contact allergic dermatitis (65.4%; 72.2%); atopic dermatitis (15.9%; 11.7%); contact irritant dermatitis (7.0%; 6.6%) and nummular eczematoid dermatitis (4.2%; 2.4%). According to occupation, positive patch test reaction was most commonly observed in workers, whereas 65% of patients showed positive reactions to one or more substances. There was an increased frequency of positive patch test reactions to potassium dichromate, nickel sulfate, thimerosal and neomycine sulfate, along with a significant decrease in the frequency of positive patch test reactions to cobalt chloride, carba mix, wood tars, detergents, parabens mixture, urushiol and rubber mixture. We strongly recommend keeping up-to-date with the epidemiology of contact allergy in Croatia.     

Persistence of contact allergy among Danish adults: an 8-year follow-up study

In 1990, a random sample of 567 persons of the 15-69-year-old population living in the Western part of Copenhagen County, Denmark, was patch tested in a cross-sectional study. In 1998, a follow-up study was performed. Out of 540 invited, 365 (68%) were re-patch tested. In the follow-up study, the persistence of allergic contact sensitivity, defined as 1 or more positive patch tests in both surveys, was 71% (37 out of 52 subjects). Nickel allergy persisted in 79% (19 out of 24 subjects), while 60% (21 out of 35 subjects) had a positive patch test reaction to 1 or more allergens, other than nickel, in both surveys. The lowest persistence was 50% (5 out of 10 subjects) and this was found for patch test reactivity to 1 or more of the cosmetic ingredients included in the patch test series. 8 years after the baseline study had demonstrated allergic contact sensitivity, 71% of the subjects still had at least 1 positive patch test. Nickel allergy persisted in 79%. Allergen avoidance should probably be lifelong to prevent elicitation of contact dermatitis.     

Cost benefit of patch testing with textile finish resins

Eleven years experience of textile finish resin patch testing of suspected textile dermatitis patients revealed 15 cases of allergic textile dermatitis among 428 patients tested. Ten of the 15 patients had a relevant positive patch test to one or more of a limited series of textile finishes; 1 was negative and 4 were not tested with textile finishes. All 15 patients were formaldehyde sensitive. No unexpected, relevant, positive textile finish resin patch test was found. In this study a negative patch test to formaldehyde virtually excluded allergic contact dermatitis from textile finishes.     

Risk assessment for nickel contact allergy

Nickel is one of the most common allergens causing allergic contact dermatitis worldwide. The aim of the study was to evaluate the contributing factors to nickel contact allergy (NiCA) in Asians who have a unique culture and lifestyle. We randomly selected 324 previously patch‐tested patients, 162 nickel patch test (PT)‐positive patients and 162 nickel PT‐negative patients. The patients were telephone interviewed for their lifestyle information. Most of the nickel PT‐positive patients (93.2%) were female with a mean age of 38.9 ± 13.3 years compared with the other group of nickel PT‐negative patients who had a smaller proportion of females (76.5%) with an older mean age of 44.1 ± 14.9 years (P = 0.001). Multivariate analysis was able to establish that the significant risk factors for NiCA were female sex (odds ratio [OR], 6.38; 95% confidence interval [CI], 2.15–18.94), young age (OR, 0.98; 95% CI, 0.96–1.00), occupation with long periods of exposure to metal (OR, 3.08; 95% CI, 1.18–8.02), seafood (OR, 1.96; 95% CI, 1.17–3.27) and canned food consumption (OR, 3.12; 95% CI, 1.17–8.33) (P < 0.05). The adjusted factors found to associate with NiCA were female sex, young age, occupation with long periods of exposure to metal, seafood and canned food consumption.     

Occupational nickel dermatitis in the electroforming industry

An outbreak of occupational dermatitis in an electroforming plant where there was heavy exposure to nickel is described. Patch test investigations confirmed nickel allergy in 13 of 27 exposed individuals. Nickel chloride was found to be a more reliable patch test allergen than nickel sulphate. Improvements in industrial hygiene led to an immediate decrease in the incidence of dermatitis. Persistent patch test sensitivity to nickel was found in three individuals who had been removed from the process chemicals for some years.