Patch Testing. In: Johansen JD, Frosch PJ, Lepoittevin J, editors. Contact Dermatitis. Berlin: Springer Berlin Heidelberg; 2011. pp. 439-64. [DOI: 10.1007/978-3-642-03827-3_24]

S3 guidelines: Epicutaneous patch testing with contact allergens and drugs - Short version, Part 1

Epicutaneous patch testing is the diagnostic standard for the detection of allergic contact dermatitis. The present guidelines are aimed at residents and board-certified physicians in the fields of dermatology and allergology as well as other medical specialties involved in establishing the indication for patch testing and its execution in patients with contact dermatitis and other forms of delayed-type hypersensitivity. The target audience also includes other health care providers and insurance funds. Based on a systematic literature search and a formal consensus process (S3), the guidelines were developed by dermatologists in collaboration with pediatricians, occupational medicine physicians, nursing staff as well as patient representatives. The systematic methodological approach and appraisal of evidence upon which the recommendations are based are outlined in a separate method report that also contains evidence tables. The guidelines address general aspects of patch testing as well as medicolegal issues. The recommendations given relate to topics such as the indication for patch testing, informed patient consent, as well as the choice of test substances, test chambers and test site, duration of exposure, reading times and interpretation of test reactions. Furthermore, recommendations are provided with respect to endogenous and exogenous factors, specific patient groups (children, pregnant women, immunosuppressed individuals) as well as possible risks and adverse events associated with patch testing using contact allergens. Note: This publication is part 1 of the short version of the S3 guidelines for "Epicutaneous patch testing using contact allergens and drugs" (registry no. 013 - 018; date: March 20, 2019; valid until December 31, 2021). Part 2 of the short version will be published in the next issue. The long version of these guidelines can be accessed at www.awmf.org. The method report is available as online publication (https://www.awmf.org/leitlinien/detail/ll/013-018.html) and contains the evidence tables in its appendix.

A review of shampoo surfactant technology: consumer benefits, raw materials and recent developments

Surfactants form the core of all shampoo formulations, and contribute to a wide range of different benefits, including cleansing, foaming, rheology control, skin mildness and the deposition of benefit agents to the hair and scalp. The purpose of this review was to assist the design of effective, modern, shampoo surfactant technologies. The mechanisms through which surfactants help deliver their effects are presented, along with the appraisal techniques through which surfactant options can be tested and screened for product development. The steps that should be taken to select the most appropriate blend of surfactants are described, and useful information on the most widely used surfactants is provided. The review concludes with an examination of recent developments in 'greener' surfactants, 'sulphate-free' technologies and structured liquid phases for novel sensory properties and for suspending benefit agents.

A variant of the CXCL11 gene may influence susceptibility to contact allergy, particularly in polysensitized patients

BACKGROUND

Hereditary factors may influence individual susceptibility to contact allergy.

OBJECTIVES

To investigate genetic variants with impacts on early inflammatory reactions and T cell functions that possibly increase the risk of contact allergy.

PATIENTS AND METHODS

Three hundred and seventy two patients undergoing patch testing were recruited from the Information Network of Departments of Dermatology (IVDK). Of these, 133 were monosensitized and 239 were polysensitized, defined as reacting to three or more unrelated sensitizers. Within the polysensitized individuals, a subgroup with at least one particularly strong patch test reaction (strong reactors; n = 194) was considered. Three hundred and forty-seven blood bank donors served as controls. Fifteen genetic variants in 13 genes were analysed.

RESULTS

The homozygous variant CXCL11 AA genotype (rs6817952) was significantly more frequent among polysensitized patients (10 of 239 = 4.2%; p = 0.0048; odds ratio 7.49; 95%CI: 1.7-36.1) than among monosensitized patients (2.2%) and in the control group (0.6%). None of the remaining genetic variants investigated were characterized by similarly strong associations. However, the significance was lost after correction for multiple comparisons.

CONCLUSIONS

The homozygous variant CXCL11 genotype is associated with an increased risk of contact allergy. To confirm this exploratory finding, further independent studies are needed.

Differences in contents of organochlorine impurities do not influence responses to patch testing with Majantol®

BACKGROUND

Majantol® [2,2-dimethyl-3-(3-methylphenyl)propan-1-ol; CAS no. 103694-68-4] has been identified as a contact allergen in humans, despite negative animal tests. Hence impurities, specifically organochlorines, in Majantol® might have been the reason for positive patch test reactions in the past.

OBJECTIVES

To assess elicitation via patch testing with a standard market-quality version of Majantol® ('normal') with a normal content of organochlorine impurities, as compared with an ultra-purified version of Majantol® ('pure'), without detectable organochlorine impurities.

METHODS

Between 1 October 2013 and 31 December 2014, two different Majantol® patch test preparations of the above-mentioned quality were tested 5% pet. in parallel in the 'monitor series', that is, together with the baseline series, in 8005 consecutive patients from 33 departments of dermatology of the Information Network of Departments of Dermatology (IVDK).

RESULTS

Fifty-three of 7740 [0.69% (95%CI: 0.51-0.87)] patch tested patients reacted to at least one Majantol® preparation. The majority (n = 32) (60.4%) reacted to both preparations, 13 (24.5%) reacted to the 'normal' version only, and 8 (15.1%) reacted to the 'pure' version only. There was good concordance between results [Cohen's kappa 0.75 (95%CI: 0.65-0.85)], and there was no significant difference in frequency or intensity between the two preparations. More doubtful or irritant reactions than positive reactions were observed, and> 80% of all positive reactions were weak positive.

CONCLUSION

Organochlorine impurities are very probably not the cause of allergic reactions to Majantol®.

[Contact allergies in the German workforce : Data of the IVDK network from 2003-2013]

BACKGROUND

In Germany, occupational skin diseases rank first in the occupational skin disease statistics for many years. Especially, occupationally acquired contact allergies as well as multi-sensitization are the most important predictors for a poor prognosis and persistent eczema.

OBJECTIVES

To update the spectrum and sensitization frequencies of most frequent allergens from the standard series in Germany in patients with occupationally acquired type IV sensitizations in general and within different occupational groups.

METHODS

Data of all employed patients (age range: 16-68 years, n = 14234) patch tested between 2003 and 2013 in the German Departments of the Information Network of Departments of Dermatology (IVDK) and diagnosed occupationally acquired contact dermatitis after patch testing were analyzed. The control group was composed of all other patients (n = 31706) within the same time frame, in which occupationally acquired allergic contact dermatitis was negated explicitly.

RESULTS

The prevalence Ratio (PR; indicating risk) was significantly increased for: Thiuram-mix (PR 5.63 95 %CI 4.97-6.4), zinkdiethyldithiocarbamate (PR 6.22 95 %CI 4.76-8.22), mercaptobenzothiazole (MBT) (PR 3.88 95 %CI 3.09-4.89), mercapto-mix without MBT (PR 3.23 95 %CI 2.59-4.03), N-isopropyl-N'-phenyl-p-phenylene diamine (IPPD) (PR 2.3195 %CI 1.87-2.86), epoxy resin (PR 2.82 95 %CI 2.45-3.25), chloromethylisothiazolinone/methylisothiazolinone (MCI/MI) (PR 2.19 95 %CI 1.97-2.42) and compositae mix II (PR 2.05 95 %CI 1.45-2.89). They were the predominant occupational allergens and were at least associated with a doubled risk (PR ≥ 2.0) for acquiring occupationally allergic contact dermatitis. The highest risk increase was identified in employees in the health services, in agriculture, metal industry, food and service industry as well as building trades

CONCLUSIONS

A limited number of occupationally relevant allergens cause the majority of sensitizations in the workforce, if standard series allergens are concerned. Data analysis of national and international contact allergy data bases provide valuable information on sensitization rates and profiles in skin risk occupations to implement targeted prevention strategies. To diagnose occupational allergic contact dermatitis in individual cases additional testing of occupation related patch test series as well as patients' own products is commonly inevitable.

Lettuce contact allergy

Lettuce (Lactuca sativa L.) and its varieties are important vegetable crops worldwide. They are also well-known, rarely reported, causes of contact allergy. As lettuce allergens and extracts are not commercially available, the allergy may be underdiagnosed. The aims of this article are to present new data on lettuce contact allergy and review the literature. Lettuce is weakly allergenic, and occupational cases are mainly reported. Using aimed patch testing in Compositae-allergic patients, two recent Danish studies showed prevalence rates of positive lettuce reactions of 11% and 22%. The majority of cases are non-occupational, and may partly be caused by cross-reactivity. The sesquiterpene lactone mix seems to be a poor screening agent for lettuce contact allergy, as the prevalence of positive reactions is significantly higher in non-occupationally sensitized patients. Because of the easy degradability of lettuce allergens, it is recommended to patch test with freshly cut lettuce stem and supplement this with Compositae mix. As contact urticaria and protein contact dermatitis may present as dermatitis, it is important to perform prick-to-prick tests, and possibly scratch patch tests as well. Any person who is occupationally exposed to lettuce for longer periods, especially atopics, amateur gardeners, and persons keeping lettuce-eating pets, is potentially at risk of developing lettuce contact allergy.

Skin sensitization

Skin sensitization associated with allergic contact dermatitis is a common health problem and is an important consideration for toxicologists in safety assessment. Historically, in vivo predictive tests have been used with good success to identify substances that have the potential to induce skin sensitization, and these tests formed the basis of safety evaluation. These original tests are now being replaced gradually either by in vitro assays or by further refinements of in vivo methods such as the local lymph node assay. Human data have also been available to inform classification decisions for some substances and have been used by risk managers to introduce measures for exposure reduction. However, humans encounter hazards in the context of exposure rather than in the form of intrinsic hazards per se, and so in this article, we have examined critically the extent to which human data have been used to refine classification decisions and safety evaluations. We have also evaluated information on the burden of human allergic skin disease and used this to address the question of whether, and to what extent, the identification and evaluation of skin sensitization hazards has led to an improvement of public and/or occupational health.

High prevalence of contact allergy in adolescence: results from the population-based BAMSE birth cohort

BACKGROUND

Contact allergy is common among adults. However, little is known about the prevalence in adolescents.

OBJECTIVES

To assess the prevalence of allergy to common contact allergens in Swedish adolescents in the general population.

PARTICIPANTS AND METHODS

The BAMSE cohort is a population-based birth cohort with the main aim of studying the risk factors for asthma, rhinitis, and atopic dermatitis. Patch testing was performed at the 16-year follow-up. The test (TRUE Test(®) ) was applied at home, and removed 2 days later by nurses, who recorded and photographed the results. Dermatologists made final assessments on the basis of photographs and protocols.

RESULTS

Two thousand two hundred and eighty-five participants (88% of all 16-year follow-up participants) were patch tested; 15.3% had at least one positive reaction. Contact allergy was more common in girls than in boys (17.0% versus 13.4%, p = 0.018). Sensitization to nickel was most common (7.5%), followed by sensitization to fragrance mix I (2.1%) and p-tert-butylphenol formaldehyde resin (1.9%). Nickel allergy was more frequent in girls (9.8% versus 4.9%, p < 0.001). Solitary sensitization to cobalt was more common than co-sensitization to nickel and cobalt.

CONCLUSIONS

The prevalence of contact allergy in adolescents is of almost the same high magnitude as in adults. The applied method was feasible in the population-based setting.

EAACI position paper for practical patch testing in allergic contact dermatitis in children

INTRODUCTION

Allergic contact dermatitis (ACD) in children appears to be on the increase, and contact sensitization may already begin in infancy. The diagnosis of contact dermatitis requires a careful evaluation of a patient's clinical history, physical examination, and skin testing. Patch testing is the gold standard diagnostic test.

METHODS

Based on consensus, the EAACI Task Force on Allergic Contact Dermatitis in Children produced this document to provide details on clinical aspects, the standardization of patch test methodology, and suggestions for future research in the field.

RESULTS

We provide a baseline list of test allergens to be tested in children with suspected ACD. Additional tests should be performed only on specific indications.

Patch test results in children and adolescents across Europe. Analysis of the ESSCA Network 2002-2010

BACKGROUND

Contact sensitization in children is more frequent than previously thought.

METHODS

The ESSCA collected patch test data from 11 European countries aggregated to 4 European regions.

RESULTS

Six thousand and eight patients aged 1-16 years old with suspected allergic contact dermatitis were analyzed during a period of 8 years (2002-2010). The overall prevalence of at least one positive reaction to a hapten was 36.9%. The 10 most frequent haptens were as follows: nickel sulfate, cobalt chloride and potassium dichromate, neomycin sulfate, Myroxylon pereirae resin (balsam of Peru), para-phenylenediamine, chloromethylisothiazolinone/methylisothiazolinone 3:1, fragrance mix, lanolin alcohols, and colophony. No difference was found in the prevalence of at least one positive reaction to at least one hapten between boys and girls and between children with atopic dermatitis and children without. Children without atopic dermatitis, when compared with those with, had a significantly higher prevalence of contact sensitization for nickel sulfate (20.91% vs 16.87%, respectively), 4-tert. butylphenol formaldehyde resin (1.61% vs. 0.7%), and para-phenylenediamine (2.49% vs. 1.3%).

LIMITATIONS OF THE STUDY

Chamber loading is not an exact science and variation may occur between staff and departments. Interinstitution variations in readings can occur. A possible geographic confounder is that the southern regions tested more children in the younger age group. Relevance was not addressed due to difficulties in the application of a set of uniform definitions.

CONCLUSIONS

Our study adds information on the most common contact allergens detected in children which could help to define a Standard European Pediatric Baseline Series.

European Society of Contact Dermatitis guideline for diagnostic patch testing - recommendations on best practice

The present guideline summarizes all aspects of patch testing for the diagnosis of contact allergy in patients suspected of suffering, or having been suffering, from allergic contact dermatitis or other delayed-type hypersensitivity skin and mucosal conditions. Sections with brief descriptions and discussions of different pertinent topics are followed by a highlighted short practical recommendation. Topics comprise, after an introduction with important definitions, materials, technique, modifications of epicutaneous testing, individual factors influencing the patch test outcome or necessitating special considerations, children, patients with occupational contact dermatitis and drug eruptions as special groups, patch testing of materials brought in by the patient, adverse effects of patch testing, and the final evaluation and patient counselling based on this judgement. Finally, short reference is made to aspects of (continuing) medical education and to electronic collection of data for epidemiological surveillance.

Contact allergy induced by bisphenol A diglycidyl ether leachables from aluminium tubes for pharmaceutical use

BACKGROUND

Aluminium tubes for pharmaceutical use are internally lacquered with epoxy resins (ER) based on bisphenol A diglycidyl ether (BADGE). Recently, it was shown that remnants of ER polymerization like BADGE are extractable from epoxy-based coatings of commercially available tubes and may leach into semi-solid drug preparations. We aimed to evaluate the safety of BADGE-contaminated macrogol ointments in individuals sensitized to ER based on BADGE by use tests.

METHODS

Repeated open application testing (ROAT) in 11 patients sensitized to ER based on BADGE with BADGE in macrogol ointments (3 mg/kg; 30 mg/kg, equivalent to BADGE concentration determined in macrogol ointment after storage in a commercially available tube; 300 mg/kg).

RESULTS

The 30 mg/kg BADGE ointment elicited reactions in three patients, and another three patients reacted to 300 mg/kg BADGE ointment. No reactions to the vehicle control and 3 mg/kg BADGE were observed.

CONCLUSIONS

Elevated BADGE concentrations in ER-coated aluminium tubes pose a risk of developing contact dermatitis to patients sensitized to ER based on BADGE. Quality standards are deemed necessary for the production of ER-coated aluminium tubes intended for pharmaceutical use and should consider the results of the present ROAT study.

Sunflower seeds as eliciting agents of Compositae dermatitis

BACKGROUND

Sunflowers may cause dermatitis because of allergenic sesquiterpene lactones (SLs). Contact sensitization to sunflower seeds has also been reported, but the allergens are unknown.

OBJECTIVES

To analyse sunflower seeds for the presence of SLs and to assess the prevalence of sunflower sensitization in Compositae-allergic individuals.

PATIENTS/MATERIALS/METHODS

Sunflower-sensitive patients were identified by aimed patch testing. A dichloromethane extract of whole sunflower seeds was analysed by liquid chromatography-mass spectrometry and high-performance liquid chromatography.

RESULTS

The prevalence of sensitivity to sunflower in Compositae-allergic individuals was 56%. A solvent wash of whole sunflower seeds yielded an extract containing SLs, the principal component tentatively being identified as argophyllin A or B, other SLs being present in minute amounts.

CONCLUSIONS

The concentration of SLs on the sunflower seeds is considered high enough to elicit dermatitis in sensitive persons, and it seems appropriate to warn Compositae-allergic subjects against handling sunflower seeds.

Consideration of criteria required for assignment of a (skin) sensitiser a substance of very high concern (SVHC) under the REACH regulation

The identification, characterisation, risk assessment and risk management of materials that cause allergic sensitisation is an important requirement for human health protection. It has been proposed that for some chemical and protein allergens, and in particular for those that cause sensitisation of the respiratory tract (associated with occupational asthma), it may be appropriate to regard them as Substances of Very High Concern (SVHC) under the provisions of REACH (Registration, Evaluation, Authorisation and restriction of CHemicals). We have argued previously that categorisation of sensitising agents as SVHC should be used only in exceptional circumstances. In the present article, the subject of SVHC is addressed from another perspective. Here the information that would be required to provide a compelling case for categorisation of a skin sensitising substance as a SVHC is considered. Three skin sensitising chemicals have been identified to serve as working examples. These are chromate, a potent contact allergen, and the skin sensitisers formaldehyde and isoeugenol. The key criterion influencing the decision regarding a skin sensitiser being categorised as SVHC is the extent to which impacts on the quality of life are reversible. Consequently, SVHC categorisation for skin sensitising chemicals should be used only in exceptional circumstances.

Risk factors of polysensitization to contact allergens

BACKGROUND

'Polysensitization' (PS) is usually defined as contact sensitization to three or more unrelated haptens of the baseline patch test series. Despite PS being an important clinical phenotype indicating increased susceptibility to contact allergy, statistical approaches to analyse PS have hitherto been preliminary.

OBJECTIVES

To apply an appropriate regression model for count data, namely, negative binomial hurdle regression, to a large set of clinical patch test data with the aim of estimating PS risk in more detail than previously achieved.

METHODS

The detailed information provided by the hurdle model includes a separate estimation of an 'increment factor' quantifying the likelihood of further positive reactions, i.e. PS. Clinical data of 126 878 patients patch tested by departments comprising the IVDK (Information Network of Departments of Dermatology) network (www.ivdk.org) between 1995 and 2010 were included.

RESULTS

Regarding anatomical sites as exposure (surrogate), the axillae and the feet were found to be strong PS risk factors. Moreover, age was a strong PS risk factor, and less so, female sex. In comparison, atopic eczema and occupational dermatitis were less important risk factors. Single allergens contributed to PS to a varying extent.

CONCLUSIONS

The data presented point to some, very likely exposure-related, risk factors which need to be considered in future PS research, e.g. addressing the genetic basis for PS.

Contact sensitization to calocephalin, a sesquiterpene lactone of the guaianolide type from cushion bush (Leucophyta brownii, Compositae)

BACKGROUND

Cushion bush [Leucophyta brownii Cass. = Calocephalus brownii (Cass.) F. Muell.] is an Australian Compositae shrub that has been introduced into Scandinavia as a pot plant. The first case of sensitization occurred in a gardener, and the main allergen was identified as the guaianolide calocephalin.

OBJECTIVE

To present the identification of the main allergen, and to assess the prevalence of sensitization to calocephalin in Compositae-allergic patients.

MATERIALS AND METHODS

Calocephalin was isolated from a dichloromethane extract of aerial parts of cushion bush. Calocephalin 0.1% ethanol was included in the plant series in Malmö, Sweden, and Odense, Denmark.

RESULTS

Nuclear magnetic resonance (NMR) analysis of calocephalin resulted in a revision of its chemical structure to 4α-acetoxy-1α,2α-epoxy-5α,10αH-guai-11(13)-en-12,8β-olide. The prevalence of patch test positivity was up to 28% in aimed patch testing. Despite strongly positive patch test reactions, the relevance was unknown in the majority of cases, and only 1 person was occupationally sensitized.

CONCLUSION

Calocephalin is a potent contact allergen, but, as cushion bush is a low-maintenance pot plant, primary sensitization is most likely to occur through occupational exposure. Positive reactions in Compositae-sensitive persons probably occur because of cross-reactivity, and patients should be warned about contact with cushion bush plants.

Clinical course of occupational irritant contact dermatitis of the hands in relation to filaggrin genotype status and atopy

BACKGROUND

Filaggrin loss-of-function mutations and atopy may alter the clinical course of irritant contact dermatitis (ICD).

OBJECTIVE

To investigate the clinical course of patients with occupational ICD according to loss-of-function mutations in the filaggrin gene (FLG) and atopy.

METHODS

In a prospective cohort study, the clinical course, use of topical corticosteroids, sick leave, recovery rate and job continuation were investigated in 459 inpatients treated for occupational ICD of the hands. Patients were genotyped for four FLG mutations, examined for atopy and followed for up to 3 years after discharge.

RESULTS

Our study included 327 (71·2%) atopic individuals and 132 nonatopic individuals. Overall, 68 patients showed a mutation in the FLG alleles R501X, R2447X, S3247X and 2282del4 (60 atopic and eight nonatopic). Nonatopic patients with ICD responded well to therapeutic approaches, while atopy status made subjects more resistant to therapy, resulting in lower rates of recovery and job continuation and higher use of topical corticosteroids. Carriage of FLG loss-of-function mutations in combination with atopy worsened the course. The risk of abandoning one's profession in this group was significantly increased when compared with 'pure' ICD (odds ratio 3·1) after 3 years.

CONCLUSIONS

Patients with atopy are a special risk population for ICD. In the presence of atopy, FLG mutations seem to be a modifier of the severity of the clinical course in ICD. Early-stage identification of this subgroup may result in additional emphasis to these patients regarding the importance of adherence to specific therapeutic interventions.

Impact of atopic dermatitis and loss-of-function mutations in the filaggrin gene on the development of occupational irritant contact dermatitis

BACKGROUND

Atopic dermatitis (AD) and loss-of-function mutations in the filaggrin gene (FLG) are both associated with chronic irritant contact dermatitis (ICD). As FLG mutations also are a major risk factor for AD, it is not clear whether FLG mutations are an independent risk factor for ICD or whether the risk is mediated by AD.

OBJECTIVES

To investigate the relative contribution and interaction of FLG mutations and AD in German patients with occupational ICD and controls (vocational school apprentices).

METHODS

A total of 634 patients and 393 controls were genotyped for R501X, 2282del4, R2447X and S3247X. Current or past flexural eczema was used as an indicator of AD.

RESULTS

FLG mutations were found in 15·9% of the patients with ICD and 8·3% of the controls, with a crude odds ratio (OR) of 2·09 [95% confidence interval (CI) 1·33-3·28] for the combined genotype. The adjusted OR for FLG mutations, corrected for AD, was 1·62 (95% CI 1·01-2·58). Subjects with AD were at approximately three times higher risk of developing ICD than controls (OR 2·89; 95% CI 2·09-3·99). There was no evidence of an interaction between these two risk factors.

CONCLUSIONS

Our results indicate that both FLG mutations and AD increase the risk of ICD. Individuals with concurrent FLG mutations and AD are at the highest risk of developing ICD.