The Role of Textiles in Dermatitis: An Update

Standard and Expanded Series Patch Testing Update by the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC)

After the meeting held by the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC) back in October 2021, changes were suggested to the Spanish standard series patch testing. Hydroxyethyl methacrylate (2% pet.), textile dye mixt (6.6% pet.), linalool hydroperoxide (1% pet.), and limonene hydroperoxide (0.3% pet.) were, then, added to the series that agreed upon in 2016. Ethyldiamine and phenoxyethanol were excluded. Methyldibromoglutaronitrile, the mixture of sesquiterpene lactones, and hydroxyisohexyl 3-cyclohexene (Lyral) were alo added to the extended Spanish series of 2022.

[Translated article] Standard and Expanded Series Patch Testing Update by the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC)

After the meeting held by the Spanish Contact Dermatitis and Skin Allergy Research Group (GEIDAC) back in October 2021, changes were suggested to the Spanish Standard Series patch testing. Hydroxyethyl methacrylate (2% pet.), textile dye mixt (6.6% pet.), linalool hydroperoxide (1% pet.), and limonene hydroperoxide (0.3% pet.) were, then, added to the series that agreed upon in 2016. Ethyldiamine and phenoxyethanol were excluded. Methyldibromoglutaronitrile, the mixture of sesquiterpene lactones, and hydroxyisohexyl 3-cyclohexene (Lyral) were also added to the extended Spanish series of 2022.

Early-Life Exposure to Formaldehyde through Clothing

Clothes contain a wide range of chemicals, some of them potentially hazardous. Recently, there has been a growing interest in eco-friendly clothing, including the use of organic cotton. However, the process of eco-friendly fabric production does not exclude the use of toxic substances, such as formaldehyde, a known human carcinogen. The present investigation was aimed at determining the presence of formaldehyde in eco-friendly and conventional clothing of pregnant women, babies, and toddlers from the Catalan (Spain) market. The potential effects of washing were also investigated by comparing the reduction of formaldehyde in unwashed and washed clothing. Formaldehyde was detected in 20% of samples, with a mean level of 8.96 mg/kg. Formaldehyde levels were surprisingly higher in eco-friendly than in regular garments (10.4 vs. 8.23 mg/kg). However, these differences were only significant (p < 0.05) for bras (11.6 vs. 7.46 mg/kg) and panties (27.1 vs. 6.38 mg/kg) of pregnant women. Dermal exposure and health risks were assessed for three vulnerable population groups: pregnant women, babies, and toddlers. In general, exposure was higher in babies (up to 1.11 × 10−3 mg/kg/day) than in other groups (2.58 × 10−4 and 4.50 × 10−3 mg/kg/day in pregnant women and toddlers, respectively). However, both non-carcinogenic and carcinogenic risks were below the safety limits (<1 and <10−5, respectively) according to national regulations. Notwithstanding, although formaldehyde levels were below the legal limits (<75 mg/kg) and health risks were within acceptable ranges, clothing may contain other toxic substances in addition to formaldehyde, thus increasing the risks. Finally, since no formaldehyde was detected in washed textile samples, a safe and simple practice for the consumers is to wash clothing before the first use.

Flare management in atopic dermatitis: from definition to treatment

Atopic dermatitis (AD) is a skin immune-mediated inflammatory disease with a chronic-recurrent course. Acute exacerbations or flares are an integral part of the AD course and are generally defined as disease worsening, requiring escalation/intensification of treatment. Management of flares is crucial since their prevention is a key aim of long-term disease control. Nevertheless, difficulties related to this aspect are several, starting from the definition of flare itself, which is not always satisfactory or unambiguous, and needs clarification. Indeed, this hurdle may reduce clarity on treatment choice and generate difficulties when comparing data between studies. Deepening our knowledge on flares could be highly relevant to both clinicians and patients to provide adequate control of the disease through patient education and appropriate treatment. This review aims to summarize current knowledge on the management of AD flares from definition to treatment, highlighting aspects that are still unclear, and identifying any necessary unmet needs to better manage AD.

Bikini textile contact dermatitis: A Sherlockian approach revealing 2.4-dichlorophenol as a potential textile contact allergen

BACKGROUND

Different textile constituents may act as allergens and/or irritants and provoke textile contact dermatitis (TCD).

OBJECTIVES

To report a case of TCD caused by ethylene glycol monododecyl ether and 2.4-dichlorophenol, present in a bikini.

METHODS

A woman presented with an eczematous, pruritic rash in the area of the bikini straps and back. Patch testing was performed with the European baseline, textile, sunscreen, and photo-patch series, the bikini "as is", and ethanol and acetone extracts of the bikini. Thin-layer chromatography (TLC) of the extracts and gas chromatography-mass spectrometry (GC-MS) analysis were used to elucidate the culprit agents.

RESULTS

Positive reactions were found to the bikini "as is" and to the ethanol and acetone extracts. Patch testing with TLC strips showed a strong reaction to spots-fractions 3 and 4. GC-MS was performed to identify substances in each fraction and those suspected to be skin sensitisers were patch tested. On day (D) 4 positive reactions to ethylene glycol monododecyl ether (irritant reaction) and 2.4-dichlorophenol (++) were observed.

CONCLUSION

A myriad of chemical compounds can be found in clothing. Ethylene glycol monododecyl ether and 2.4-dichlorophenol were identified as the potential culprits of this bikini TCD.

HIGHLIGHTS

We have combined chemical analyses (thin-layer chromatography and gas chromatography-mass spectrometry) to study a case of textile contact dermatitis. As such, the presence of a myriad of chemical compounds was found in a bikini, suggesting that clothing in general may become impregnated or contaminated by a wide range of external substances that may be harmful to the skin. Textile contact dermatitis could in this case be attributed to ethylene glycol monododecyl ether (CAS No. 4536-30-5) and 2.4-dichlorophenol (CAS No. 120-83-2), the latter not yet previously described as a textile contact allergen.

The Future of Functional Clothing for an Improved Skin and Textile Microbiome Relationship

The skin microbiome has become a hot field of research in the last few years. The emergence of next-generation sequencing has given unprecedented insights into the impact and involvement of microbiota in skin conditions. More and more cosmetics contain probiotics or bacteria as an active ingredient, with or without scientific data. This research is also acknowledged by the textile industry. There has been a more holistic approach on how the skin and textile microbiome interacts and how they influence the pH, moisture content and odour generation. To date, most of the ingredients have a broad-spectrum antibacterial action. This manuscript covers the current research and industry developments in the field of skin and textiles. It explores the nature of antimicrobial finishing in textiles which can disrupt the skin microbiome, and the benefits of more natural and microbiome friendly therapies to combat skin conditions, malodour and skin infection.

Patch Test Results to European Baseline Series in Turkey: A Prospective and Multicenter Study

BACKGROUND

Patch testing with the European Baseline Series (EBS) is an essential diagnostic tool for the assessment of allergic contact dermatitis.

OBJECTIVE

The aims of the study were to describe the most common contact allergens identified with patch testing in Turkey and to establish the distribution of contact allergens among different regions in Turkey.

PATIENTS AND METHODS

Twelve centers consisting of tertiary health care institutions were included in the study. A total of 1169 patients were patch tested with the EBS from 2015 to 2017.

RESULTS

A total of 596 patients (51.0%) had 1 or more positive patch test reactions to the EBS. A total of 30.2% (n = 353) of those tested had clinical relevance. Contact sensitivity was more common in young patients. The most common 10 allergens were nickel sulfate (20.4%), followed by textile dye mix (8.6%), cobalt chloride (8.3%), potassium dichromate (8.0%), p-phenylenediamine base (4.5%), balsam of Peru (4.3%), methylchloroisothiazolinone/methylisothiazolinone (3.8%), thiuram mix (3.6%), fragrance mix I (3.0%), and methylisothiazolinone (2.9%).

CONCLUSIONS

This study provides a comprehensive profile of patch test results with the EBS in Turkey. An ongoing decrease in contact allergy to methylchloroisothiazolinone/methylisothiazolinone and methylisothiazolinone was observed. Textile dye mix and p-phenylenediamine are beginning to pose a new risk in Turkey.

Fabric Selection in Atopic Dermatitis: An Evidence-Based Review

BACKGROUND

Clothing fabrics interact closely with the skin to shape our cutaneous microenvironment. Cotton and silk have been traditionally recommended for patients with atopic dermatitis because of reported patient comfort. New synthetic fabrics combine anti-microbial, anti-inflammatory, moisture-wicking, and soothing properties that may augment conventional management strategies in atopic patients.

OBJECTIVE

We review existing and emerging evidence for fabric selection in patients with atopic dermatitis including cotton, wool, lyocell, silk, anionic, cellulosic/cellulose based, zinc oxide coated, citric acid coated, chitosan coated, silver coated, borage seed oil coated, ethylene vinyl, and polyurethane and offer practical suggestions for clothing and bedding choices.

METHODS

A systematic search was conducted on PubMed and EMBASE electronic databases for articles from 1 January, 1994 to 1 January, 2020. Studies were included based on the following inclusion criteria: clinical trial, published in English, and fabric as the main agent being evaluated. Case reports, case series, conference abstracts, reviews, animal studies, and duplicates were excluded. Studies were then manually screened by title, abstract, and full-text articles and selected to specifically describe the effects of fabrics in patients with atopic dermatitis. Both adult and pediatric patient studies were included.

RESULTS

There appears to be an advantage to modern fabric manufacturing and processing techniques that have created smaller diameter, smoother fibers such as super- and ultrafine merino wool and anti-microbial finishes. Traditional cotton and silk fabrics have mixed evidence in improving atopic dermatitis symptoms and severity but have shown to be generally safe. Large-diameter wool has been shown to induce itching and irritation; ultra- or superfine merino wool is non-pruritic and may be recommended as an alternative. Emerging fabrics with potential efficacy in reducing atopic dermatitis severity and Staphylococcus aureus burden include silver-coated, chitosan-coated, and cellulose-based fabrics. Zinc oxide-coated, acid-coated, polyurethane-coated, borage seed oil-coated, anionic, lyocell, and ethylene vinyl fabrics have sparse evidence and require further study before conclusions can be made.

CONCLUSIONS

Appropriate fabric selection can reduce the symptom severity and exacerbations of atopic dermatitis.

Human exposure to trace elements, aromatic amines and formaldehyde in swimsuits: Assessment of the health risks

Nowadays, most of the swimsuits are mainly made of artificial fibres, which have interesting properties such as water repellence and fast drying. Swimsuits contain a wide range of additives, which can mean a hazard for the environment and/or human health. In this study, the concentrations of formaldehyde (free and water soluble), 24 aromatic amines, and 28 trace elements (Ag, Al, As, B, Ba, Be, Bi, Cd, Co, Cr, Cu, Fe, Hg, Mg, Mn, Mo, Ni, Pb, Sb, Sc, Se, Sm, Sr, Sn, Tl, Ti, V and Zn) were analysed in 39 swimsuits covering a wide range of materials, colours and brands. Dermal exposure and health risks were assessed for adults (men and women) aged > 18 years old, babies between 2 and < 3 years old, children (boys and girls) between 3 and < 6 years old and 6 and < 11 years old, and teenagers (boys and girls) between 11 and < 16 years old, wearing swimsuits for 4 h or 8 h. Formaldehyde and aromatic amines were below their respective detection limits in all samples (<16 and < 1.5 mg/kg, respectively). Regarding trace elements, Ti showed the highest mean levels (1844 mg/kg), being significantly higher in polyamide (3759 mg/kg) than in polyester (24.1 mg/kg) swimsuits. These high Ti levels were confirmed by environmental scanning electron microscope in a single sample made of polyamide. Increased concentrations of Cr were also observed, but only in polyamide black fabrics, with values ranging from 624 to 932 mg/kg. Non-cancer risks (hazard quotients) derived from the exposure to trace elements were in a safe zone for all analysed trace elements. Furthermore, the carcinogenic risks were evaluated for As, Cr and Pb, exhibiting values below the 10^-5 threshold, with the exception of Cr in babies and children-girls. For Ti, health risks could not be calculated due to the lack of information on toxicological data. However, because Ti was the element with the highest concentrations in swimsuits, and taking into account the potential toxicity of TiO2 nanoparticles, further research is needed to assess the migration of this element from fibres to skin.

Risk assessment due to dermal exposure of trace elements and indigo dye in jeans: Migration to artificial sweat

The concentration of a number of trace elements (Ag, Al, As, B, Ba, Be, Bi, Cd, Cr, Co, Cu, Fe, Mg, Mn, Mo, Ni, Pb, Sb, Sc, Se, Sm, Sr, Sn, Tl, Ti, V and Zn) were determined in 42 commercialized denim garments (jeans and shirts), being dermal exposure subsequently assessed. Migration experiments with artificial acid and basic sweat were also conducted to determine the release of these elements, as well as indigo dye. In a similar way than for the total content, Mg (124 and 99.4 µg/g) and Mn (27.1 and 7.20 µg/g) showed the highest concentrations in both artificial sweat, acid and basic, respectively. Indigo dye migrated at levels ranged from 3.22 to 7.76 mg/g, being higher in dark than in light blue fabrics. The levels of trace elements and indigo were analysed according to materials of fabric, colour, brand, and eco-labelling. Using total content and migrations rates, dermal exposure to trace elements for adult men, women and teenagers were calculated under the two sweat extractions. Non-carcinogenic and carcinogenic risks due to dermal exposure to the elements here analysed in cloths were assessed. Both risks were in the limits of safe to according to international regulations. However, the maximum exposure to Sb reached a hazard quotient (HQ) of 0.3 in clothes partially made of polyester. Despite some authors have established that indigo is an agonist of the aril receptor, health risks due to exposure to indigo dye were not calculated due the lack of toxicological data.

A Real-Life Based Evaluation of the Effectiveness of Antibacterial Fabrics in Treating Atopic Dermatitis

BACKGROUND

Antibacterial clothes are classified as a complementary treatment in line with antisepsis, although meta-studies are unable to find significant improvements of eczemas.

METHODS

The antibacterial effectiveness of conventional AD clothes was compared across each other by (i) standard suspension tests for the appraisal of antibacterial products and (ii) a real-life setup of affected AD skin using S. aureus colonised artificial skin, to assess if functional clothes are effective under practical wear conditions. Additionally, the interaction of the fibre types with a moisturising cream was evaluated during a real wearing situation and after domestic laundry.

RESULTS

In the real-life setup simulating dry skin microenvironment, all samples failed to reduce S. aureus. Silver and zinc-fabrics showed a slight activity only under unrealistic moist conditions. When using standard suspension tests, samples differed considerably in their antibacterial effectiveness, where silver and zinc endowed fibres outperformed AEGIS endowed silk fabrics. Garments absorbed the cream dependent on the particular fibre types. Furthermore, domestic laundry was unable to completely remove the cream.

CONCLUSION

Considerable differences in the antibacterial effectiveness of conventional AD clothes were revealed. Under practical (dry) wear conditions, garments were unable to modify skin colonization with S. aureus, although effectiveness can be triggered by wetting the garments. Remnants of moisturising cream remain on the fibres after laundry.

Consensus Conference on Clinical Management of pediatric Atopic Dermatitis

The Italian Consensus Conference on clinical management of atopic dermatitis in children reflects the best and most recent scientific evidence, with the aim to provide specialists with a useful tool for managing this common, but complex clinical condition. Thanks to the contribution of experts in the field and members of the Italian Society of Pediatric Allergology and Immunology (SIAIP) and the Italian Society of Pediatric Dermatology (SIDerP), this Consensus statement integrates the basic principles of the most recent guidelines for the management of atopic dermatitis to facilitate a practical approach to the disease. The therapeutical approach should be adapted to the clinical severity and requires a tailored strategy to ensure good compliance by children and their parents. In this Consensus, levels and models of intervention are also enriched by the Italian experience to facilitate a practical approach to the disease.