Adverse skin reactions to nicotine in a transdermal therapeutic system

Nicotine in a transdermal therapeutic system (TTS) has been introduced recently to help people to stop smoking. 14 volunteers (10 male, 4 female) with a history of former adverse skin reactions to this device were investigated. Skin tests for contact urticaria and patch tests for contact allergy were done with the individual components of the TTS. Contact sensitization to nicotine was identified in 5 and to the TTS itself in 1 individual. Irritant reactions due to occlusion were present in 9 subjects. The optimal test agent and concentration for elucidating the adverse skin reaction was an aqueous solution of 10% nicotine base. Atopy, as diagnosed by history and skin prick tests to common inhalant allergens, and contact sensitization to standard patch test allergens, were each identified in 6 subjects. Nicotine should be added to the expanding list of transdermally delivered drugs which may elicit contact dermatitis.     

A review of contact dermatitis associated with transdermal therapeutic systems

The literature is reviewed for contact dermatitis associated with transdermal therapeutic systems. Clonidine, nitroglycerin, scopolamine, estradiol and testosterone are utilized in such applications, and fentanyl is under investigation. Most cutaneous reactions are limited to localized dermatitis; however, generalized systemic effects may occur. Investigators are reporting skin-related side-effects in up to 50% of patients using transdermal clonidine; however, with the other agents, this is demonstrated much less frequently. Reactivation of the dermatitis via oral medication, following sensitization to the patch, is noted in rare instances.     

Occupational allergic contact dermatitis caused by nitroglycerin

Irritant contact dermatitis caused by occupational contact with nitroglycerin has been known since the end of the last century. Nitroglycerin is an allergen, and the transdermal drug delivery systems for nitroglycerin recently used to treat angina pectoris have sensitized. 4 patients with allergic contact dermatitis caused by nitroglycerin from explosives are described, and 1 patient who was sensitized by transdermal nitroplaster. On patch testing, dynamite and/or the explosive components nitroglycerin, ethylene glycol dinitrate and dinitrotoluene gave allergic reactions. The following concentrations and vehicles are suggested for patch testing: nitroglycerin 0.5-2% pet., dinitrotoluene and ethylene glycol dinitrate 0.1-0.5% pet. Persons exposed to nitroglycerin at work should try to avoid skin contact by using protective gloves. It is advisable that those who have become allergic to nitroglycerin should wear disposable protective gloves when handling explosives.     

Environmental contact factors in eczema and the results of patch testing Chinese patients with a modified European standard series of allergens

Environmental contact factors in eczema were investigated in China by clinical questionnaire and patch testing patients with a modified European standard series of allergens. 217 consecutive eczema patients were studied. Contact dermatitis (CD) was clinically diagnosed in 30% of the patients. Among the patients patch tested, 46 patients had clinically diagnosed allergic CD (ACD), 20 patients clinically had non-ACD (NACD) (including 16 cases of irritant contact dermatitis, 1 case of phototoxic contact reaction and 3 cases of asteatotic eczema) and 115 patients had clinically suspected ACD. 45 patients (98%) in the ACD group went on to have relevant patch test results. The most common ACD was from metals, fragrance materials, cosmetics and rubber materials. The most common contact allergens identified were nickel, fragrance mix, para-phenylenediamine (PPD), carba mix and thimerosal. No adverse reactions were observed to patch testing, except for pruritus in patch-test-positive patients. The positive rate of patch testing in ACD was much higher than that in NACD (98% versus 15%, P < 0.05, chi(2)-test). 60 (28%) patients had facial dermatitis (FD). Among these, 20 (33%) were confirmed as having ACD. 48 (22%) patients had hand dermatitis (HD). Among these, 7 (15%) were confirmed as having ACD. Fewer patients were confirmed as having ACD in the HD group than in the FD (15% versus 33%, P < 0.05, chi(2)-test). Although the difference was not significant, the total positivity rate in the HD group (55%) was lower than in the other groups. 65 (30%) patients had unclassified endogenous eczema (UEE). The total positive rate of patch testing in the UEE group (56%) was no different from that in the FD or HD groups. However, the relevance of positive patch tests was hard to determine in UEE. These results indicate that CD is common in eczema; relatively more patients with FD have ACD, while other factors, such as irritation, may play more of a role in HD. The total positive rate of patch testing in the UEE group was no different from that in the FD or HD groups, suggesting that patch testing should be stressed in UEE and the relevance of positive patch test results in UEE should be studied further. It is effective and safe to patch eczema patients with a modified European standard series of allergens in China.     

55 cases of allergic reactions to hair dye: a descriptive,consumer complaint-based study

Severe facial and scalp dermatitis following the use of permanent hair dyes has been reported in several cases. Para-phenylenediamine (PPD) is known as a potent contact allergen, and PPD is allowed in hair dye at a concentration of 6%. Hair dye reactions are usually diagnosed by the patients themselves, and adverse reactions to hair dye may not necessarily be recorded by the health care system, unless the reactions are especially severe. Based on this assumption, we suspected that hair dye dermatitis was occurring more frequently than reported in the literature. Consumer complaint-based data were obtained by advertising for persons with adverse reactions to hair dye. Among those responding to the advertisement, 55 cases of severe, acute allergic contact dermatitis were identified. The main symptoms were severe oedema of the face, scalp and ears, and clinically this was often mistaken for angio-oedema. The 55 cases comprised a total of 75 visits to the health service and 5 admissions to hospital. 18 persons had sick leave, which supports the impression of very severe dermatitis reactions. 60% were treated with antihistamine, while 52% were treated with corticosteroids. 29% of the cases were patch tested and all were found positive to PPD. Our data presented here clearly show that PPD and its derivatives in hair dye at the present concentrations presents a significant health risk for the population. Furthermore, the severe acute allergic skin reactions are often misdiagnosed in the health care system. The frequency of allergic contact dermatitis resulting from hair dye is likely to be underestimated. New methods to survey the frequency of adverse reactions should be considered.     

Allergic contact dermatitis from transdermal buprenorphine

Background: Buprenorphine is a low‐molecular‐weight, lipophilic, opioid analgesic. The transdermal delivery system (TDS) containing it has skin irritation potential, but at least two cases of contact allergy to the active principal have been described previously. Objective: To confirm allergic contact dermatitis from transdermal buprenorphine (TDB) in five older patients suffering from chronic pain and who developed persistent, pruritic erythematous plaques at the contact sites, with two of them also presenting with a generalized skin eruption. Methods: Besides the baseline patch test series, all five patients were tested with the TDB, four of whom were also tested with the placebo transdermal delivery system as provided by the manufacturer; one patient was also tested with other preparations containing buprenorphine. Results: All reacted to the TDB containing the active principal, the placebo being negative in the four patients tested. The patient tested with the other buprenorphine preparations did react positively to them as well. Tests with TDB in 28 healthy controls were negative. Conclusion: We report five cases of delayed hypersensitivity reactions to a TDS containing buprenorphine. Such adverse reactions might be under‐reported. A fentanyl‐containing TDS is a good alternative in these cases.     

用欧洲标准变应原系列检测变应性接触性皮炎

目的　观察欧洲标准变应原系列在我国斑贴试验应用中的可行性。方法　对 181例门诊患者进行了斑贴试验。其中确诊变应性接触性皮炎患者 46例 ,非变应性接触性皮炎患者 2 6例 ,可疑变应性接触性皮炎患者 10 9例。结果　确诊变应性接触性皮炎患者中阳性 45例 ;非变应性接触性皮炎患者阳性 6例 ;斑贴试验的灵敏度为 97.8% ,特异度 76.9% ,准确性 90 .3 % ,阳性预测值 88.2 % ,阴性预测值 95 .2 %。除瘙痒外 ,未见不良反应。可疑变应性接触性皮炎患者结果与以往报告类似。结论　该试剂在我国应用安全有效。     

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.     

Patch testing in discoid eczema

We report a retrospective study of patch testing in patients with discoid eczema. 48 patients with persistent or severe discoid eczema were patch tested. The mean age of patients was 45 years and the median duration of symptoms was 6 months. 24 patients (50%) had positive patch tests, and 16 of these (33%) were considered to be clinically relevant. The most common allergens implicated were rubber chemicals, formaldehyde, neomycin, chrome, nickel (5, 2, 2, 2, 2, 2 reactions, respectively). 13 of 16 patients were followed up by telephone in 1996, and 8/13 (61%) slated they had benefited from patch testing. This study suggests allergic contact dermatitis is relatively common in persistent discoid eczema, and allergen avoidance may be of benefit. We recommend patch testing should be considered for all patients with severe or persistent discoid eczema.     

Hand eczema in car mechanics

To estimate the prevalence of hand eczema, a questionnaire was distributed to 901 male car mechanics. Of the 801 persons who responded, 15% reported hand eczema on some occasion in the previous 12 months, and 57% admitted dry skin on the hands. In a 2nd part of the study, those who reported hand eczema were examined and patch tested with a standard series and a special "car mechanics' series". The most common diagnosis was irritant contact dermatitis, 55%, and 2nd was allergic contact dermatitis, 19%. 35/105 (33%) had a total of 51 positive patch test reactions, all to substances in the standard series, except for 2 persons who reacted to oxidized d -limonene. The most frequent reactions were to thimerosal (9%), nickel (8%) and colophony (5%). One plausible explanation for the high prevalence of nickel allergy was the common use of nickel-plated tools. 5 individuals had a history of contact urticaria, but scratch tests were negative. It was concluded that car mechanics are at high risk for contact dermatitis on the hands, irritant as well as allergic.     

Patch testing in allergic contact dermatitis: is it useful to perform the cosmetic series in addition to the European standard series?

Background Cosmetics are the causative agents in 8–15% of patients suspected of having allergic contact dermatitis. Patch testing with standard series identifies 70–80% of the responsible allergens in all contact dermatitis; however, many important cosmetic‐related allergens may be missed by using standard series alone. Objective The aim of this study was to determine the value of using cosmetic series in addition to the European standard series in patients with suspected allergic contact dermatitis. Methods In this prospective study, 93 consecutive patients suspected of having allergic contact dermatitis were patch tested with the European standard series, and simultaneously with cosmetic series. Positive allergic reactions were further interpreted as clinically relevant or irrelevant. The clinically relevant reactions were subsequently stratified into three subgroups: (i) reactions only to allergen/allergens in the European standard series; (ii) reactions only to allergen/allergens in cosmetic series; and (iii) reactions both to allergen/allergens in the European standard and cosmetic series. Results A total of 74 positive reactions were observed in 93 patients. However, only 46 (62.2%) of the total positive reactions were found to be clinically relevant. Of all the clinically relevant positive reactions, 27 (58.7%) were caused by the allergens in the European standard series; 19 (41.3%) were caused by the allergens in cosmetic series. Of the 93 patients tested, 44 (47.3%) had at least one positive allergic reaction, 30 (68.2%) of whom had clinically relevance. Of the 30 patients with clinically relevant positive tests, 16 (53.3%) reacted only to allergens in the European standard series; nine (30%) reacted only to cosmetic series allergens; and five (16.7%) reacted both to the European standard and cosmetic series allergens. Among the 45 cosmetic series allergens tested, 15 (33.3%) gave positive reactions of which 14 (93.3%) of those were found to be clinically relevant. The clinically relevant cosmetic series allergens which were found to be over the critical incidence of 1% included methyldibromo glutaronitrile, Euxyl K400, and isopropyl myristate. Conclusion Patch testing with cosmetic series in addition to the European standard series increased the capability to detect the relevant allergen/allergens, particularly in patients with a suspicion of cosmetic allergy. However, it is not practical and cost‐effective to test those patients routinely with all 45 allergens in the cosmetic series. As the European baseline series which includes methyldibromo glutaronitrile is now widely used as the guideline minimum set of allergens for routine diagnostic patch test investigations, we additionally recommend Euxyl K400 and isopropyl myristate as the candidates for patch testing.     

Skin diseases in workers at a perfume factory

The aim of this study is to find out the causes of skin diseases in one-third of the staff of a perfume factory, in which 10 different perfume sprays were being manufactured. Site inspection, dermatological examination and patch testing of all 26 persons at risk with 4 perfume oils and 30 ingredients of them. The results showed 6 bottlers were found suffering from allergic contact dermatitis, 2 from irritant contact dermatitis, 12 workers showed different strong reactions to various fragrances. The main causes of allergic contact dermatitis were 2 perfume oils (12 cases) and their ingredients geraniol (12 cases), benzaldehyde(9), cinnamic aldehyde (6), linalool, neroli oil, terpenes of lemon oil and orange oil (4 each). Nobody was tested positive to balsam of Peru. Job changes for office workers, packers or printers to other rooms, where they had no longer contact with fragrances, led to a settling. To conclude, automation and replacement of glass bottles by cartridges from non-fragile materials and using gloves may minimize the risk.     

Evaluation of patch testing in patients with chronic vulvar symptoms

The Dermogynaecology Clinic was established at the Mercy Hospital for Women in 1989. Since its inception, 700 patients have been investigated and 15% were clinically diagnosed as having contact dermatitis. Primary irritant dermatitis was regarded as the common cause but to investigate the place of contact allergy 50 patients were patch tested to a standard battery, medicaments, preservatives, corticosteroids and miscellaneous allergens. Twenty-one patients (42%) had a total of 44 positive tests. The most common positive reactions were to nickel (22%), cobalt (6%), fragrances (12%). caine mix (6%) and ethylenediamine (8%). Medicaments and fragrances were regarded as important allergens. Corticosteroid and imidazole allergy was not a problem in this series of patients.     

Allergic contact dermatitis from allyl isothiocyanate in a Danish cohort of 259 selected patients

Allyl isothiocyanate is present in many plants. Allergic contact dermatitis from allyl isothiocyanate is well known but infrequently reported. The aim of this study was to investigate the prevalence of contact allergy to allyl isothiocyanate in patients with suspected contact dermatitis from vegetables and food. 259 such patients were tested at the Department of Dermatology, Gentofte Hospital, Denmark, from 1994 to 2003. Only 2 patients (0.8%) had a positive reaction (+) to allyl isothiocyanate and 43 patients (16.6%) had a ?+ reaction. One of the patients with a positive reaction provided samples of margarine, salad cream, oil and mayonnaise. These were analysed with high‐performance liquid chromatography, and a moderate concentration of allyl isothiocyanate (2.5 ppm) was detected in the sample of margarine. This patient was a professional sandwich maker presenting with fingertip dermatitis mimicking ‘tulip fingers’ or allergic contact dermatitis from garlic and onions. In conclusion, allergic contact dermatitis from allyl isothiocyanate occurs in only a limited number of cases, despite frequent exposure. The large number of ?+ reactions raises the question as to whether the recommended patch test concentration is too low.     

Targeted testing with diethylthiourea often reveals clinically relevant allergic contact dermatitis caused by neoprene rubber

Background. Diethylthiourea is widely used in the rubber industry, particularly in neoprene rubber, and may cause allergic contact dermatitis. However, as thiourea allergens are not part of the European baseline series, the diagnosis of allergic contact dermatitis caused by thiourea compounds depends on clinical suspicion and aimed testing. Objectives. The aims of this study were to evaluate the occurrence of sensitization to diethylthiourea during a 19‐year period by using data from the Allergen Bank database at the Department of Dermatology and Allergy Centre, Odense University Hospital, and to evaluate whether the yield of aimed patch tests with diethylthiourea differed between the dermatologists in practice and those working in the dermatology department. Patients and methods. A total of 239 patients were patch tested with diethylthiourea 1% in petrolatum obtained from the Allergen Bank. The records for patients with positive reactions were evaluated retrospectively. Results. One hundred and fifty‐one patients were tested by 27 different dermatologists in private practice, and positive reactions were found in 16% (24/151) of the patients; 88 patients were tested at the dermatology department, and positive reactions were found in 15% (13/88). Thus, 15% (37/239) had positive patch test reactions to diethylthiourea, all with current clinical relevance and all strong. Conclusion. Clinical suspicion of neoprene rubber allergy and subsequent aimed patch testing with diethylthiourea give a high yield of clinically relevant allergic patch test reactions for both dermatologists in practice and dermatologists in the hospital department.     

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%.     

A clinical and patch test study of contact dermatitis from traditional Chinese medicinal materials

Putative allergens in, clinical manifestations of, and patch tests with traditional Chinese medicinal materials (CMM) causing contact dermatitis (CD) were studied. 14 patients with CMM CD and 351 controls were patch tested with the standard series of allergens of Beijing Medical University and the suspected drug, as is. It was found that most CMM CD was caused by the CMM frequently used topically for analgesic and anti-inflammatory effect. All patients patch tested with the suspected drug gave positive results. Some patients also reacted to fragrance mix. Colophony, rubber mix and ammoniated mercury. The positively rates of fragrance mix and colophony in CMM CD patients were significantly higher than in controls (55.6% versus 16.5% for fragrance mix, X ²= 11. 86, P < 0.01; and 55.6% versus 5.1% for colophony, X ²= 29.35. P < 0.01), while not those of rubber mix and ammoniated mercury. Results indicated that the topical analgesic and anti-inflammatory CMM, especially those containing fragrance, may cause contact sensitization. Clinical findings in CMM CD included cutaneous irritation, allergic contact dermatitis. immediate contact reactions and systemic contact dermatitis. CMM CD can he diagnosed by patch testing the putative drug, as is.     

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.     

Occupational allergic contact dermatitis and patch test results of leather workers at two Indonesian tanneries

Background. Tannery workers are at considerable risk of developing occupational contact dermatitis. Occupational skin diseases in tannery workers in newly industrialized countries have been reported, but neither the prevalence of occupational allergic contact dermatitis nor the skin‐sensitizing agents were specifically examined in those studies. Objectives. To assess the prevalence of occupational allergic contact dermatitis in Indonesian tanneries, identify the causative allergens, and propose a tannery work series of patch test allergens. Patients/methods A cross‐sectional study in all workers at two Indonesian tanneries was performed to assess the prevalence of occupational contact dermatitis via a questionnaire‐based interview and skin examination. Workers with occupational contact dermatitis were patch tested to identify the causative allergens. Results. Occupational contact dermatitis was suspected in 77 (16%) of the 472 workers. Thirteen (3%) of these 472 workers were confirmed to have occupational allergic contact dermatitis. Potassium dichromate (9.2%), N,N‐diphenylguanidine (5.3%), benzidine (3.9%) and sodium metabisulfite (2.6%) were found to be the occupationally relevant sensitizers. Conclusions. The sensitization pattern showed some differences from the data in studies reported from other newly industrial countries. We compiled a ‘tannery work series' of allergens for patch testing. A number of these allergens may also be considered for patch testing in patients with (leather) shoe dermatitis.     

Hand eczema: causes, course, and prognosis I

Background:  Hand eczema is a common dermatosis. The course is often protracted. The prognosis is not well described.
Objective:  To describe in detail a consecutive cohort of hand eczema patients with regard to aetiology and morphology as well as the dynamics of the hand eczema.
Patients and Methods:  This prospective study included 522 consecutive patients (175 men and 347 women with hand eczema) seen in 1 year in a private practice of dermatology. 425 (81%) of the patients were patch tested in relation to the current study. Most of the remainder had been previously patch tested.
Results:  38% had mild dermatitis, 49% had dermatitis of moderate severity, and 11% had severe dermatitis. 23% had had dermatitis for more than 10 years. 33% had irritant contact dermatitis, 13% of the men and 20% of the women had allergic contact dermatitis, and 15% of the men and 16% of the women had atopic dermatitis. For 34% of the men and 29% of the women, the dermatitis was certainly or possibly occupational. There was no relationship to smoking.
Conclusions:  The majority of this cohort of hand eczema patients had long-standing disease. Irritant contact dermatitis was the most common aetiological diagnosis.