Case of allergic contact dermatitis due to 1,3‐butylene glycol

1,3‐Butylene glycol (1,3‐BG) is widely used in cosmetics, including low‐irritant skin care products and topical medicaments, as an excellent and low‐irritation humectant. We report a case of allergic contact dermatitis caused by 1,3‐BG. A 28‐year‐old woman suffered from an itchy erythematous eruption on her face. By 2 days of closed patch testing, her own cosmetics and many of the hypo‐irritant skin care products showed positive results. A second patch testing showed positive reaction to 1,3‐BG (1% and 5%). 1,3‐BG was a common component in most of the products that had elicited a positive reaction in the first patch testing. Although allergic contact dermatitis due to 1,3‐BG is not so common, we have to consider 1,3‐BG as a possible contact allergen in the patients presenting with allergic contact dermatitis due to various cosmetics.     

Allergic contact dermatitis from stearamidoethyl diethylamine phosphate: a cosmetic emulsifier

Contact dermatitis to the emulsifier stearamidoethyl diethylamine phosphate was demonstrated in 4 patients. In 3 patients, the emulsifier was present in a commonly used over-the-counter dry skin lotion and in the 4th in a deodorant. In 2 cases, the patients overtly suspected that the product was the cause of the dermatitis. Patch tests to the products were positive. The emulsifier was identified as the contact allergen after testing with coded deletion and/or individual ingredient samples provided by the manufacturer. No apparent cross reactions were found from testing with the standard screening tray of the North American Contact Dermatitis Group or in one case to 2 structurally similar emulsifiers. No other positive reactions to the emulsifier were found after testing it routinely in one patch test clinic for 1 year. Repeated insult (prophetic) patch testing with the final formulation of the dry skin lotion (as performed by the manufacturer) was negative for sensitization and irritation.     

Are adverse skin reactions to cosmetics underestimated in the clinical assessment of contact dermatitis? A prospective study among 1075 patients attending Swedish patch test clinics

It is known that cosmetics and skin care products can cause adverse skin reactions. However, the frequency of adverse reactions reported to the Medical Product Agency (MPA) in Sweden is low. The purpose of the present study was to evaluate the occurrence of adverse skin reactions to cosmetics among patients referred for standard patch testing owing to suspected contact dermatitis in general, most frequently hand eczema. Consecutive patients at four patch test clinics in Sweden were invited to participate; 1075 were included. Of these, 47.3% (54.2% women and 30.8% men) reported current or previous adverse skin reactions to cosmetics and skin care products. This group showed significantly more positive patch test reactions, a higher prevalence of atopic dermatitis and the dermatitis was more frequently located in the face and neck region. Our results show that patients referred for standard patch testing have--or have had--a large proportion of self-reported adverse reactions to cosmetics or skin care products. We conclude that among patients with suspected contact dermatitis, adverse reactions to cosmetics can be a more important aetiological and/or complicating factor than is commonly acknowledged and that the reporting of such reactions to the MPA probably can be improved.     

Allergic contact dermatitis to preservatives

In summary, a wide variety of skin care products contain preservatives. Patients who are allergic to one of these preservatives may have either localized or widespread dermatitis. Affected patients may find it difficult to avoid thimerosal without the help of the health care provider because the use of these allergens is so widespread. Patch testing is an invaluable tool for patients who struggle with dermatitis. Antigen-avoidance lists that facilitate patient education about what products to avoid are available from the manufacturers of patch test allergens (for example, TRUE Test or Chemotechnique). These lists are helpful starting points for patients in that they provide general categories (for example, shampoos, soaps, or creams) of products that the patient should avoid. With these printed guidelines alone, patients must read skin care product labels carefully, looking for the names of their allergens as identified by patch tests as well as for any synonyms and cross-reactors of these allergens. Thus, patients may feel overwhelmed by hearing the names of allergens that are long and complex. After an allergen has been identified, the nurse can play a key role in helping patients understand their dermatitis and its management. Nurses are in a unique position to spend time educating patients about how to uncover the sources of specific allergens and, subsequently, how to avoid them. The Contact Allergen Replacement Database can help in this educational process by giving patients a shopping list of specific items that are free of the specific allergens causing their allergic contact dermatitis.     

Cosmetic Allergy

A recent epidemiologic survey in the UK revealed that 23% of women and 13.8% of men experience some sort of adverse reaction to a personal care product over the course of a year. Although most of these reactions may be due to subjective sensory irritation, various studies reveal that up to 10% of dermatologic patients who are patch tested are allergic to cosmetic products or their constituent ingredients. Causative products include deodorants and perfumes, skin care products, hair care products, and nail cosmetics. Allergic contact dermatitis mainly results from fragrance chemicals and preservatives. Recent work has suggested that additional fragrance chemicals may need to be tested in order to identify those patients 'missed' by the current fragrance mix; in particular, hydroxy-isohexyl-3-cyclohexene carboxaldehyde (HMPPC Lyral) has been singled out as an important sensitizing agent. The increased usage of natural fragrances and botanic extracts can also cause problems in their own right or through co-reactivity. The preservative methyldibromo glutaronitrile has also been recognized as an increasingly important sensitizer in Europe, which has led to the recent recommendation that it should be prohibited from 'leave-on' products until information on 'safe' consumer levels becomes available. Other emerging allergens include UV filters, tosylamide/formaldehyde resin, and nail acrylates. The diagnosis of cosmetic allergy should be confirmed with patch testing, including testing of 'whole' products, when necessary, and repeat open application tests can be used to confirm the relevance of reactions in cases of doubt.     

Allergic contact dermatitis from ophthalmic products: can pre‐treatment with sodium lauryl sulfate increase patch test sensitivity?

In patients suspected of allergic contact dermatitis because of topical ophthalmic medicaments, patch tests performed with patients' own products are often negative. The irritant anionic surfactant sodium lauryl sulfate (SLS) may alter the stratum corneum and increase antigen penetration. Pre-treatment of the skin with SLS 0.5% for 24 h was performed in the sites of patch tests with patients' own products in 15 selected patients. In patients previously negative to their own products tested with conventional patch tests, SLS pre-treatment showed 6 new relevant positive reactions and induced a stronger positive reaction in 1 patient. SLS pre-treatment could be proposed as an alternative promising method, which may increase sensitivity of patch tests with patients' own products.     

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 allergy to Compositae plants in patients with summer-exacerbated dermatitis

16 patients with summer-exacerbated dermatitis were examined by patch testing and photopatch testing with a battery of Compositae and standard allergens. IgE and RAST, and the thresholds to UVA and UVB, were determined. 6 female and 2 male patients showed allergic contact reactions to one or more Compositae extracts from flowers common in Sweden, also used in skin care products. The study points to the importance of including testing with Compositae allergens in patients with summer-exacerbated dermatitis. This group comprises patients with multiple contact reactions, photosensitivity and flares of atopic dermatitis.     

The importance of a dedicated patch test clinic

BACKGROUND: A specialist patch test clinic was set up in April 1997 at the Department of Dermatology, South Infirmary-Victoria Hospital, Cork, Ireland. The number of batteries available was expanded from six to 21 and the routine testing of patients to their own products was introduced, as was prick testing for latex hypersensitivity. OBJECTIVES: To assess the impact of introducing this clinic on the detection of allergic contact dermatitis. METHODS: Patch test results for the first full year of operation of the clinic (1998) were compared with those in the year prior to setting it up (1996). RESULTS: Although the number of patients tested rose after the introduction of the new clinic, the difference was not significant as the number of new dermatology general referrals had also risen. Thirty-one of the 91 patients tested in 1996 had positive patch tests compared with 84 of 158 tested in 1998 (P = 0.0036). Eighteen allergens were detected in 1996 and 53 in 1998. Two patients were positive to their own products in 1996, compared with 12 in 1998 (P = 0.04). The commercial batteries were negative in four of these cases. Three cases of latex hypersensitivity were detected in 1998. CONCLUSIONS: The introduction of a specialist patch test clinic resulted in an increase in detected cases of allergic contact dermatitis. The larger range of batteries available and the more widespread testing of patients' own products were the principal factors involved.     

Can the reporting of adverse skin reactions to cosmetics be improved? A prospective clinical study using a structured protocol

Background:  The use of cosmetics is rising, and adverse reactions to these products are increasing. In Sweden, the Medical Products Agency (MPA) keeps a voluntary reporting system for such adverse reactions. However, the reporting is sparse, consisting almost only of cases with test-proven allergic contact dermatitis, thus under-reporting the more common irritant reactions.
Objective:  The aim of the study was to try to improve the reporting system.
Patients and Methods:  Dermatologists at 3 dermatology departments used a structured protocol during the clinical investigation of 151 consecutive patients reporting skin reactions to cosmetics. The protocol included symptoms, signs, affected body site, suspected products, and final diagnosis after patch testing. Based on clinical data and patch test results, a causality assessment for each product was made according to a protocol used at the MPA.
Results:  Allergic contact dermatitis was found in 28% of the patients, and irritant reactions were equally common at 27%.
Conclusions:  Using this structured protocol, the cases of irritant dermatitis were also reported, and it is recommended that such a protocol is used as a standard to improve the reporting of adverse reactions to skin care products.     

Peristomal allergic contact dermatitis--case report and review of the literature

Allergic contact dermatitis (ACD) is a rare cause of peristomal skin problems. Only 23 cases have previously been reported in the literature. We report the case of a colostomy patient with a severe disabling blistering peristomal dermatitis. Patch testing to a British Contact Dermatitis Society standard series, medicaments and a plastics and glues series was negative. Patch testing to the patient's own products gave a positive reaction (+) at D2 and D4 to Dansac soft paste and Stomahesive paste. Further patch testing to the components of Dansac soft paste showed a positive (+) reaction at D2 and D4 to ester of polymethyl vinyl/maleic acid copolymer (Gantrez-ES) only. This is the first reported case of ACD due to Dansac soft paste. ACD to Gantrez has previously been reported but in different products. We also review the other previously reported cases of ACD causing peristomal dermatitis and stress the importance of patch testing in these cases, in particular to the patient's own products, as avoidance of identified allergens can have a large impact on the quality of life.     

Vulvar dermatoses--irritant and allergic contact dermatitis of the vulva

Irritant and allergic contact dermatitis are commonly seen in patients complaining about itching, burning and irritation in the vulvar area. Irritation often precedes allergic sensitization. Clinically, irritant and allergic contact dermatitis can be difficult to distinguish. Diagnosis is made by history, clinical investigation and patch testing. Recommended patch test series are the standard series, a medicament series, the patient's own topical medicaments, popular remedies and other suspected products. A skin biopsy may be useful to establish the diagnosis of contact dermatitis, but it is usually not helpful for the differential diagnosis between irritant and allergic dermatitis.     

Skin care in occupational contact dermatitis of the hands

A survey of patients attending an occupational dermatology clinic with suspected occupational contact dermatitis affecting the hands was undertaken to determine if optimal skin care treatment had been instituted prior to referral for patch testing. Appropriate treatment for contact dermatitis of the hands was defined as concurrent use of a soap substitute, use of a lipid-rich moisturizer, and if appropriate, use of a topical corticosteroid in an ointment vehicle. Patients were asked about the use of a particular soap substitute, the name and type of any moisturizer used and the name and type of topical corticosteroids currently used. The products were examined where possible. Only one-third of all patients were using the complete package at the time of their clinic appointment. Nearly all of these patients had seen a dermatologist prior to this appointment. Of the group of patients with work-related diseases who reported having seen a dermatologist prior to the clinic appointment, only 38% were using the complete skin care routine.     

Occupational allergic contact dermatitis from 2,3-epoxypropyl trimethyl ammonium chloride (EPTMAC) and Kathon® LX in a starch modification factory

2.3-epoxypropyl trimethyl ammonium chloride (EPTMAO is used in the production of cationic starch (CS) for the paper industry. It has been shown to be a sensitizer in guinea pigs, but eases of human sensitization are few. 4 workers were previously sensitized to the substance in a Finnish plant. This report describes 3 process men from another plant examined because of recurring dermatitis. IS workers were involved in production, and had free access in ill work sites. 3 process men. whose work involved drying the CS, had dermatitis, although they had only occasional contact with the cationizing chemical. 2 were already verified to be allergic to EPTMAC' and had had variable dermatitis for 8–12 years. One had had dermatitis on his lace for 1 year. Patch testing with a dilution series (1%, 0.5%. 0.2%, 0.1% pet.) confirmed their allergy to the cationizing chemical containing EPTMAC, but tests with CS were negative. In addition, 2 had contact allergy to C1+ Me-isothiazolinone from contact with Kathon® LX used us a slimicide in the process. In longstanding (years) recurrent dermatitis, re-examination of patients with verified exposure history and skin tests is necessary. In line with our previous study, sampling the process materials, maintenance work and contamination of work sites and gloves caused sensitization. The results also confirm that EPTMAC is a strong human contact sensitizer. 0.2%–0.5% pure EPTMAC in pet. seem to be the optimal patch test concentration.     

The relevance of chlorhexidine contact allergy

Background. Chlorhexidine is used for disinfection of skin and mucosae in medicine and dentistry. Prolonged exposure may lead to contact sensitization and allergic contact dermatitis or stomatitis. Objectives. The purpose of this study was to analyse the sources of chlorhexidine exposure and sensitization, and to obtain data on the prevalence of sensitization and chlorhexidine‐related contact allergy. Patients and methods. From 1999, patch testing was performed with chlorhexidine digluconate (0.5% aq.) on 7610 general dermatology patients with suspected contact allergy at the Turku University Hospital Dermatology Department. The medical records were reviewed concerning the patients' exposure to chlorhexidine. Results. A positive patch reaction to chlorhexidine was seen in 36 patients (0.47%). Current dermatitis or stomatitis caused by chlorhexidine‐containing topical medicaments was seen in 5 patients. Chlorhexidine sensitization contributed to the current dermatitis in 11 patients. A history of earlier exposure to chlorhexidine‐containing products was recalled by only 16 sensitized patients, whereas no exposure was revealed in 4 cases. Conclusions. Chlorhexidine‐containing corticosteroid creams, skin disinfectants and oral hygiene products are principal sources of chlorhexidine contact sensitization. Exposure to chlorhexidine in cosmetics may lead to delayed improvement of eczema in sensitized patients, emphasizing the importance of identifying the potential cosmetic sources.     

Occupational allergic contact dermatitis due to coconut diethanolamide (cocamide DEA)

Coconut diethanolamide (CDFA). manufactured from coconut oil, is widely used as a surface-active agent in hand gels. hand-washing liquids, shampoos, and dish-washing liquids. CD HA has rarely caused allergic contact dermatitis. During NS5 IW2, we investigated 6 patients with occupational allergic contact dermatitis caused by CDEA. 2 became sensitized from a barrier cream, 3 from a hand-washing liquid, and 1 had been exposed both to a hand-washing liquid and to a metalworking fluid containing CDEA. Leave-on products (hand-protection foams) caused sensitization much more rapidly (2 3 months) than rinse-off products (hand-washing liquids: 5–7 years). Due to the extensive use of CDEA and the lack of proper declaration of products, it is difficult to avoid CDEA exposure. No contact allergy to another coconut-oil-derived sensitizer (cocamidopropyl betaine) was found in the patients.     

The additive value of patch testing with patients' own products at an occupational dermatology clinic

Background and objectives: Patch testing with commercially available kits detects only 70–80% of relevant allergens in patients with contact dermatitis. This is not ideal, especially when occupational issues are being evaluated. This study analyses our data regarding reactions to patients' own products.
Methods: In a 5-year period, 1532 patients were assessed in our occupational dermatology clinic.
Results: We found that 101 patients (6.6%) reacted to their own samples. In 20 (1.3%) cases, reacting to their own samples was the only clue for detecting the responsible allergen. In 59 (3.9%) cases, testing with their own samples reinforced their reactions to commercial allergens.
Conclusions: We found the overall additive value of testing with patients' own products to be 5.2%. This is not a low proportion considering the 20–30% false negative rate when patch testing. Patch testing with patients' own samples, appropriately diluted should be undertaken whenever possible.     

Provocative use tests in CAPB-allergic subjects with CAPB-containing product

Cocamidopropyl betaine (CAPB) has been identified as a cause of contact allergy in personal care products. Furthermore, it has been suggested that chemicals responsible are impurities, especially dimethylaminopropylamine (DMAPA). However, skin contact concentrations with these impurities, especially DMAPA, are very low. The aim of the study was to analyse whether subjects with previous positive patch tests to CAPB would react in provocative use tests of a product containing CAPB. 10 individuals with a clinical history of contact allergy to CAPB (by positive patch test and history) took part in a ROAT which used a CAPB-based shower gel at 25% (DMAPA concentration < 1 ppm). None of the subjects showed positive allergic reactions. 1 of the test subjects did experience a flare of atopic dermatitis at the treatment site. Later, all 10 subjects were patch tested to 3 different concentrations of CAPB and DMAPA (0.1%, 0.3%, 1%) to verify the threshold that was capable of inducing a positive test reaction. 5/10 showed clear + reactions to 1% CAPB (typically at D3), whilst a further 3 gave marginal and/or irritant reactions. Only 1 of the subjects showed an allergic reaction to DMAPA. Finally, in uncontrolled use testing with the shower gel, none of the test subjects reported any adverse skin reactions. Thus, the study confirmed that CAPB-sensitive individuals can use a CAPB-based rinse-off product without the risk of experiencing an allergic reaction to CAPB.     

Deodorants: an experimental provocation study with hydroxycitronellal

Axillary dermatitis is a common problem, particularly in individuals with contact allergy to fragrances. Many individuals suspect their deodorant to be the causal product of their fragrance allergy. It has been shown that deodorants containing cinnamic aldehyde (cinnamal) can elicit axillary dermatitis in patients sensitized to this substance. The aim of the present investigation was to evaluate the importance of hydroxycitronellal used in deodorants for the development of axillary dermatitis, when applied by individuals with and without contact allergy to this fragrance chemical. Patch tests with deodorants and ethanolic solutions containing hydroxycitronellal, as well as repeated open application tests (ROAT) with roll-on deodorants with and without hydroxycitronellal at different concentrations, were performed in 14 dermatitis patients, 7 with and 7 without contact allergy to hydroxycitronellal. A positive ROAT was noted only in the patients hypersensitive to hydroxycitronellal (P < 0.001) and only in the axilla to which the deodorants containing hydroxycitronellal had been applied (P < 0.001). Deodorants containing hydroxycitronellal in the concentration range of 0.032-0.32% used twice daily on healthy skin in individuals hypersensitive to hydroxycitronellal can elicit axillary dermatitis in a few weeks.     

Mercury allergy in a contact dermatitis clinic in Northern Ireland

441 consecutive patients (294 female, 147 male) with suspected contact dermatitis were patch tested to the European standard series, mercury metal (1% pet.). ammoniated mercury (1% pet.), and mercuric chloride (0.1% aq.), 14 patients (3.2%), 12 of whom were female, showed a positive response to 1 or more mercury compounds: none reacted to mercuric chloride alone. Primary sensitization was most likely due to either inoculation with vaccines containing merthiolate preservatives or amalgam dental restorations. Mercury allergy was of historical clinical relevance in only 2 pa I rents, both women who developed gingivostomatitis following insertion of amalgam dental fillings. 1 of these women subsequently developed allergic contact dermatitis from contact lens solutions, shampoos and cosmetics which contained mercury preservatives. On the basis of these findings, we recommend patch testing with both metallic mercury and ammoniated mercury in patients with suspected mercury allergy.