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 bufexamac

Thirteen cases of contact allergy to bufexamac have been seen since 1976 at the Department of Dermatology of the University of Heidelberg. Most of the patients were women (69%). Nine patients suffered from chronic eczema and four had stasis dermatitis. Four patients had used bufexamac for less than 2 weeks. Based on the case histories, about half of the patients were suspected of having contact allergy to bufexamac. The clinical picture was consistent with that of allergic contact dermatitis; a generalized eruption was observed in two cases. Eight patients had additional sensitizations; three patients were allergic to benzyl alcohol, which is used as a preservative in the bufexamac cream available commercially. Contact allergy to bufexamac seems to be rare; however, it should be considered as a cause of sensitization in patients with chronic eczema, even after short-term application.     

Delayed contact hypersensitivity to non-steroidal anti-inflammatory drugs

Several non-steroidal anti-inflammatory drugs (NSAIDs) are available for topical treatment of acute soft tissue trauma or degenerative musculoskeletal disorders; the NSAID bufexamac is mainly used for therapy of chronic inflammatory skin diseases. In order to assess the occurrence of contact allergy to NSAIDs in 371 consecutive patients presenting for diagnosis of presumed contact allergy, patch tests were performed with a standard series and additionally with a series of NSAIDs, comprising acetylsalicylic acid, bufexamac, diclofenac, etofenamate, felbinac, flufenamic acid, ibuprofen, indomethacin, and piroxicam. 17 individuals (4.6%) exhibited delayed hypersensitivity to one of the NSAID preparations: 12 patients (3.2%) had patch test reactions to bufexamac, 2 (0.5%) to etofenamate, 2 (0.5%) to indomethacin, and 1 patient (0.3%) to flufenamic acid. These patch test results corresponded well to the individual history in 11 individuals (including 10 patients with reactions to bufexamac), and in 2 patients the clinical relevance of the reactions was probable. In view of the high frequency of allergic contact reactions to bufexamac, we propose to test this drug particularly in patients with atopic eczema or other chronic eczematous diseases.     

Severe cutaneous eruptions following the topical use of preparations containing bufexamac: Is it time to reconsider its registration in Australia?

Despite being a well-recognised cause of allergic contact dermatitis with an embargo in many countries around the world, bufexamac is available over the counter in topical preparations in Australia. We present a series of patients who developed severe cutaneous eruptions after the topical application of bufexamac containing preparations to highlight the potential risks of this medication, as well as advocate for the reconsideration of its registration by the Therapeutic Goods Administration in Australia.     

Recommendation to include methyldibromo glutaronitrile in the European standard patch test series

The preservative methyldibromo glutaronitrilc (MDBGN) is used non-occupationally and occupationally. High contact allergy rates have been reported when tested in consecutive dermatitis patients as well as clinical cases with allergic contact dermatitis. Up till now there has been no agreement on which patch test preparation to use to trace contact allergy to MDBGN. From the year 2005 on, MDBGN at 0.5% w/w in petrolatum is recommended for the European standard patch test series. The choice of 0.5% is based on consideration of rates of contact allergy, doubtful and irritant reactions, as well as on information on clinical relevance represented by results of a repeated open application test, and patch test concentrations to diagnose allergic contact dermatitis from MDBGN in individual cases.     

Patch testing with methyldibromo glutaronitrile, a multicentre study within the EECDRG

Contact allergy to and allergic contact dermatitis from methyldibromo glutaronitrile (MDBGN) have frequently been reported. As there has been no agreement on which MDBGN test preparation to use, a study was initiated to help determine the optimal patch test preparation for MDBGN. 2661 consecutively patch tested patients at 11 test clinics representing 9 European countries participated. Petrolatum preparations with MDBGN at 1.0%, 0.5%, 0.3% and 0.1% were inserted in the standard series. Contact allergy rates were noted in the range 4.4-1.1% following decreasing test concentrations. Reactions not fulfilling all criteria to be classified as allergic reactions could represent either weak allergic or irritant reactions, and such reactions were noted in the range 8.2-0.5% with decreasing concentrations. A significant number of these reactions represented weak allergic reactions, as allergic reactions were obtained to higher patch test concentrations in the same individual. Morphologically irritant reactions were noted only for the highest test concentrations. In summary, the contact allergy rates and frequencies of doubtful and irritant reactions vary with the patch test concentration. The final decision on patch test concentration for MDBGN should not only rely on these factors but also include information on patch test concentrations required to diagnose individual cases with allergic contact dermatitis from MDBGN as well as results of repeated open application tests.     

Efficacy of bufexamac (NFN) cream in skin diseases. A double-blind multicentre trial.

The effect of a new non-steroid anti-inflammatory substance (bufexamac) in a special constituent was compared with that of 0.1% triamcinolone acetonide, 1% hydrocortisone cream, and placebo during a double-blind multicentre trial. The clinical effect of these four creams was studied in 193 patients receiving treatment for the following skin disorders: atopic dermatitis, allergic contact dermatitis, and non-allergic contact dermatitis, as well as dermatitis seborrheica. After 2 and 4 weeks' treatment, when 193 and 157 patients, respectively, were re-examined, the effect of triamcinolone acetonide and hydrocortisone cream was significantly better, than that obtained with bufexamac in the cream basis employed. On the other hand, no statistically significant difference in effect between bufexamac and placebo cream was observed.     

Frequency of postoperative allergic contact dermatitis to topical antibiotics.

BACKGROUND AND DESIGN--Topical antibiotics are one of the most common causes of allergic contact dermatitis and are frequently used in postoperative wound care. We prospectively followed up patients having cutaneous surgery to determine the frequency of allergic contact dermatitis to topical antibiotics used on postoperative wound care. RESULTS--Nine (4.2%) of 215 patients who had undergone surgery who were using a topical antibiotic had an eruption develop postoperatively that was consistent with an allergic contact dermatitis from the topical antibiotic. Seven of the nine patients agreed to patch testing with the standard tray and selected topical antibiotics. Five patients had a positive patch test to neomycin sulfate and four had a positive patch test to bacitracin. The frequency of allergic contact dermatitis proved by patch testing to neomycin and bacitracin is five (5.3%) of 94 and four (2%) of 198, respectively, in the patients who used these antibiotics. All proved sensitivities to bacitracin occurred in patients using a topical antibiotic that also contained neomycin and were patch tested positive to the neomycin. No patients using only pure bacitracin had allergic contact dermatitis. CONCLUSIONS--Allergic contact dermatitis to a topical antibiotic, especially neomycin, should be considered in any patient who has development of a dermatitis after cutaneous surgery. Because of the frequency of allergic contact dermatitis, neomycin-containing antibiotics should be avoided in postoperative wound care.     

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.     

Swimming pool contact dermatitis caused by 1-bromo-3-chloro-5,5-dimethyl hydantoin

Background. Bromo‐3‐chloro‐5,5‐dimethylhydantoin (BCDMH) is a chemical used as a disinfectant for recreational water. BCDMH was described as being responsible for an epidemic of irritant contact dermatitis in the UK (1983), and its sensitizing capacity was also discussed. Objectives. The aim of this study was to assess whether BCDMH used to disinfect swimming pools and spas can cause allergic contact dermatitis among its users. Methods. Ten patients suffering from dermatitis associated with using swimming pools disinfected with BCDMH and 40 controls were studied. Several dilutions of BCDMH, 10% to 1 ppm, were patch tested. Results. All 10 patients studied showed a positive patch test reaction to BCDMH 1% in petrolatum. At least one case showed occupational relevance, with a positive reaction even at 1 ppm. Conclusion. On the basis of the clinical findings, the positive patch test reactions to BCDMH, and the negative patch test reactions in controls, the suggested diagnosis was allergic contact dermatitis caused by BCDMH used as a disinfectant in the swimming pool water. Contact allergy should be taken into consideration when patients suffer from swimming pool‐associated itchy dermatitis.     

Allergic contact dermatitis to topical minoxidil solution: etiology and treatment.

After more than a decade of use, topical minoxidil solution has proven to be a safe and effective treatment for androgenetic alopecia. However, some patients present with complaints of pruritus and scaling of the scalp. The most common causes of these symptoms include irritant contact dermatitis, allergic contact dermatitis, or an exacerbation of seborrheic dermatitis. Patients suffering from allergic contact dermatitis may benefit from patch testing to determine the causative allergen. Among the patients we patch tested, propylene glycol was found to be the contactant in a majority of cases, not the minoxidil itself. Many of these patients may be candidates for treatment with alternative formulations using other solvents, such as butylene glycol, polysorbate, or glycerol. Although predictive, patch testing results do not ensure that the compounded preparations will be tolerated. Unfortunately, patients found to be allergic to minoxidil are no longer candidates for topical treatment of their alopecia with any preparations of minoxidil.     

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 prevalence in patients with otitis externa.

A statistical analysis of the relationship between otitis externa and various clinical and etiological variables was carried out in 64 patients. Between 1988 and 1989, true eczema of the auditory canal was found in 43 of the 64 patients seen sequentially. 23.5% of all the patients found to have dermatitis could be regarded as having allergic contact dermatitis and the allergen identified. This incidence is less than the 40% and the 58% found in other previous studies. We did not find any specific difference in sex and age between the allergic and non-allergic groups. In the allergic group, topical drugs were the commonest sensitizing agents, followed by chemicals and resins found in the ear prosthesis. Twenty-one patients with negative patch tests were classified as seborrheic dermatitis and 11 as atopic dermatitis. The other 19 patients, who were discharged before patch testing, were diagnosed as having psoriasis (8) or chronic bacterial (6) or fungal infections (5), without true blister reaction. We think that accurately selected series must be used for these studies because of the low incidence of allergic contact dermatitis.     

Contact dermatitis to para‐phenylenediamine in hair dye following sensitization to black henna tattoos – an ongoing problem

Summary Background: The increased frequency of case reports of allergic contact dermatitis from non‐permanent black henna tattoos in recent years shows the popularity of this form of body painting. Patients and methods: Seven patients presented with allergic contact dermatitis after initial hair or eyelash dyeing. They all had a history of a previous reaction from a black henna tattoo. All were patch tested with the European standard patch test series and the standard supplemental series, as well as special series for dyes and hairdressers. Results: All seven patients showed a positive reaction in patch testing with para‐phenylenediamine (PPD) (0.3 % and/or 1.0 % in pet.). Five patients also had positive reactions to other dyes such as aminophenol, para‐toluene diamine, disperse orange and yellow and four patients reacted to benzocaine. These were interpreted as cross‐reactions. The time from sensitization by the black henna tattoo to the onset of allergic contact dermatitis after hair dyeing was an average of 6.2 years. Conclusions: The most common cause of allergic contact dermatitis after black henna tattoos is PPD. Both the long skin contact and the high concentrations of PPD increase the risk of sensitization. Allergic contact dermatitis may be followed by post‐inflammatory hyper‐ or hypopigmentation, scarring and lifelong sensitization, which can have occupational impact, especially for hair dressers and cosmeticians.     

Contact allergy to glucocorticosteroids in patients with chronic venous leg ulcers, atopic dermatitis and contact allergy

The aim of the study was to assess the prevalence of contact allergy to glucocorticosteroids in patients with chronic venous leg ulcers (CVLU), atopic dermatitis (AD) and contact dermatitis (CD), and in a group of healthy individuals; and to estimate differences among these patient groups. Patch tests with the European standard series, antibiotics, glucocorticosteroid contact allergy screening markers and ointment vehicles were performed in a population of 140 patients. Positive patch tests results were recorded in 80% and contact allergy to glucocorticosteroids in 40% of CVLU patients. In the group of AD patients, the respective figures were 30% and 3%. In the group of CD patients, allergic type of disease was detected in 80% and positive patch tests for glucocorticosteroids in 20% of patients. In healthy individuals, allergic contact reaction was observed in 17% of cases. Statistically significant differences among patient groups were found according to the prevalence of contact allergy, polyvalent allergy and contact allergy to glucocorticosteroids. We suggest that glucocorticosteroid contact allergy should be considered as a crucial clinical problem in patients with inflammatory dermatoses like CVLU, AD and CD.     

Contact allergy to corticosteroids in patients using inhaled or intranasal corticosteroids for allergic rhinitis or asthma.

BACKGROUND: Patients using topically applied corticosteroids are at risk of developing allergic contact hypersensitivity. OBJECTIVE: To assess prevalence of allergic contact hypersensitivity reactions to inhaled or intranasal corticosteroids. METHODS: A prospective study of 30 adult patients using inhaled or intranasal corticosteroids for conditions such as allergic rhinitis was performed. We used epicutaneous patch testing to determine the prevalence of allergic contact hypersensitivity to corticosteroids and common additives (propylene glycol and benzalkonium chloride) in inhaled and nasal corticosteroid preparations in this population. RESULTS: Of 30 patients, 4 (13%) had positive patch test results. 3 (10%) were allergic reactions and 1 (3%) was an irritant reaction. Half of the reactions were to a corticosteroid (budesonide) and half were to a common preservative in nasal preparations (benzalkonium chloride). CONCLUSION: This study supports other clinical evidence that contact dermatitis/mucositis from inhaled or intranasal corticosteroid products can occur. The corticosteroids or added agents such as preservatives can be causative and may result in allergic or irritant reactions, which can be relevant to clinical symptoms.     

Skin acceptance of transcutaneous nitroglycerin patches: a prospective study of 33 patients

Transdermal nitroglycerin is commonly used and may induce contact dermatitis. The frequency of adverse skin reactions is controversial and may vary from 10% to 75%, according to various authors. 33 patients using transdermal nitroglycerin for more than 7 days were examined and patch tested (nitroglycerin 0.5% aq., 2% pet. and TTS in toto). 5 patients (15%) had adverse reactions. The patch tests were all negative in the 33 patients. Contact dermatitis occurs in many cases, about 15% of the cases with the newly available TTS, and even if patients respect the conditions for using TTS. These contact dermatitides are mainly irritant reactions and do not require transdermal nitroglycerin treatment to be stopped. Nevertheless, since some cases of allergic contact dermatitis have been reported, a contact dermatitis from transdermal nitroglycerin should lead to patch testing.     

Relationship of occupation to contact dermatitis: Evaluation in patients tested from 1998 to 2000

BACKGROUND: Both irritant and allergic contact dermatitis can be influenced by occupational and nonoccupational environmental exposures. OBJECTIVE: The aim of this study is to compare the occupations and allergens of occupational contact dermatitis cases with nonoccupational contact dermatitis cases. METHODS: Diagnostic patch testing was conducted with the 50 screening allergens of the North American Contact Dermatitis Group and occupational coding by the Surveillance Branch of the National Institute of Occupational Safety and Health. RESULTS: Of the 5,839 patients patch tested for contact dermatitis, 1,097 (19%) were deemed to be occupationally related. Of the occupational cases, 60% were of allergic and 32% were of irritant origin. The hands were the primary body part affected in 64% of allergic occupational cases and 80% of irritant occupational cases. Epoxy resin was the only allergen tested that was associated more with an occupational exposure than nonoccupational exposure. The allergens encountered most frequently in the occupational cases were carba mix, thiuram mix, epoxy resin, formaldehyde, and nickel. The medical field is overrepresented in the data compared with other occupations. CONCLUSIONS: Occupational contact dermatitis frequently was found to be multifactorial and associated with several specific allergens and occupations.     

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.     

Allergic contact dermatitis from the synthetic fragrances Lyral and acetyl cedrene in separate underarm deodorant preparations

The case is reported of a 28-year-old man who developed allergic contact dermatitis from 2 synthetic fragrance ingredients, Lyral (3- and 4-(4-hydroxy-4-methylpentyl)-3-cyclohexene-1-aldehyde) and acetyl cedrene, in separate underarm deodorant preparations. The implications of the patient's negative patch test reactions to the European standard series (Trolab) and cosmetics and fragrance series (both Chemotechnique Diagnostics) are discussed. The importance is stressed of patch testing with the patient's own preparations when cosmetic dermatitis is suspected, and of identifying and reporting offending fragrance ingredients, with a view possibly to updating the European standard series and commercially available cosmetics and fragrance series.