Contact Dermatitis in Atopic Dermatitis Children—Past, Present, and Future

Antioxidant Activity of Quercetin-Containing Liposomes-in-Gel and Its Effect on Prevention and Treatment of Cutaneous Eczema

Cutaneous eczema is a kind of skin disease is characterized by inflammation. The main manifestations are various types of dermatitis, eczema, and urticaria. There are usually complications such as erythema, blisters, and epidermal peeling. The quercetin might have a therapeutic effect on cutaneous eczema due to its favorable antioxidant activity and anti-inflammatory effects. Currently, there are few studies on transdermal administration of antioxidant drugs for the treatment of cutaneous eczema. The aim of this study was to prepare quercetin-containing liposomes-in-gel (QU-LG), its antioxidant properties were evaluated, and it was used in the skin of mice suffering from dermal eczema to see if it had preventive and therapeutic effects in an attempt to make it a new option for the treatment of cutaneous eczema. QU-LG was prepared by the injection method to form the quercetin-containing liposomes (QU-L) and evenly dispersed in the natural dissolution of carboxymethylcellulose sodium (1%, CMC-Na). The release of QU-LG across the dialysis membranes was up to 30% and clearance of 1,1-diphenyl-2-picrylhydrazyl (DPPH) was 65.16 ± 3.513%. In anti-oxidation assay QU-LG inhibited malondialdehyde (MDA) production in liver better than the commercially available drug dexamethasone acetate cream. Compared with untreated mice, mice treated with QU-LG showed a statistically significant reduction in dermatopathologic symptoms. The results suggested that QU-LG had good antioxidant activity in vivo and in vitro and could be used for the prevention and treatment of cutaneous eczema.

Advancing the understanding of allergic contact dermatitis: from pathophysiology to novel therapeutic approaches

Allergic contact dermatitis (ACD) is a common inflammatory skin disease that, especially when the condition becomes chronic, has a high impact on the quality of life and represents a significant disease burden. ACD represents a type IV delayed-type hypersensitivity reaction that is triggered by contact with an allergen in previously sensitized individuals through the activation of allergen-specific T cells. In the acute phase, it is characterized by eczematous dermatitis, which presents with erythema, edema, vesicles, scaling, and intense itch. Non-eczematous clinical forms are also described (lichenoid, bullous, and lymphomatosis). Lichenification is the most common clinical picture in the chronic phase if the culprit allergen is not found or eliminated. ACD can be associated with both occupational and non-occupational exposure to allergens, representing approximately 90% of occupational skin disorders along with irritant contact dermatitis. Patch testing with suspected allergens is required for a diagnosis. Metals, especially nickel, fragrance mix, isothiazolinones, and para-phenylenediamine, are the most commonly positive allergens in patients patch tested for suspected ACD. The treatment goal is to avoid contact with the culprit agent and use topical and/or systemic corticosteroid therapy.

Design and Evaluation of Paeonol-Loaded Liposomes in Thermoreversible Gels for Atopic Dermatitis

Paeonol (PAE) is a hydrophobic drug. In this study, we encapsulated paeonol in a lipid bilayer of liposomes (PAE-L), which delayed drug release and increased drug solubility. When PAE-L was dispersed in gels (PAE-L-G) based on a poloxamer matrix material for local transdermal delivery, we observed amphiphilicity, reversible thermal responsiveness, and micellar self-assembly behavior. These gels can be used for atopic dermatitis (AD), an inflammatory skin disease, to change the surface temperature of the skin. In this study, we prepared PAE-L-G at an appropriate temperature for the treatment of AD. We then assessed the gel’s relevant physicochemical properties, in vitro cumulative drug release, and antioxidant properties. We found that PAE-loaded liposomes could be designed to increase the drug effect of thermoreversible gels. At 32 °C, PAE-L-G could change from solution state to gelatinous state at 31.70 ± 0.42 s, while the viscosity was 136.98 ± 0.78 MPa.S and the free radical scavenging rates on DPPH and H2O2 were 92.24 ± 5.57% and 92.12 ± 2.71%, respectively. Drug release across the extracorporeal dialysis membrane reached 41.76 ± 3.78%. In AD-like mice, PAE-L-G could also relieve skin damage by the 12th day. In summary, PAE-L-G could play an antioxidant role and relieve inflammation caused by oxidative stress in AD.

[Translated article] Haptens, Proteins, and Atopic Dermatitis

Atopic dermatitis is a chronic inflammatory disease that is multifactorial in nature. Allergic contact dermatitis and protein contact dermatitis are allergic conditions that may occur in the context of atopic dermatitis and be the cause of exacerbations. Although the prevalence of allergic contact dermatitis is similar in atopic patients and the general population, these 2 conditions are frequently associated because atopic inflammation disrupts the skin barrier. Skin tests are therefore recommended in atopic individuals. Dupilumab could be useful for treating allergic contact dermatitis if it is mediated by type 2 helper T cells but could exacerbate inflammation if mediated by T_H1 cells: further study is needed before conclusions can be drawn. Although the mechanism by which exposure to environmental proteins exacerbates atopic dermatitis remains under discussion, such exacerbations are routinely seen in clinical practice. Prick testing is recommended in symptomatic atopic dermatitis. When prick-test findings are positive, patients should be advised to avoid the culprit substances.

Haptens, Proteins, and Atopic Dermatitis

Atopic dermatitis is a chronic inflammatory disease that is multifactorial in nature. Allergic contact dermatitis and protein contact dermatitis are allergic conditions that may occur in the context of atopic dermatitis and be the cause of exacerbations. Although the prevalence of allergic contact dermatitis is similar in atopic patients and the general population, these 2 conditions are frequently associated because atopic inflammation disrupts the skin barrier. Skin tests are therefore recommended in atopic individuals. Dupilumab could be useful for treating allergic contact dermatitis if it is mediated by type 2 helper T cells but could exacerbate inflammation if mediated by T_H1 cells: further study is needed before conclusions can be drawn. Although the mechanism by which exposure to environmental proteins exacerbates atopic dermatitis remains under discussion, such exacerbations are routinely seen in clinical practice. Prick testing is recommended in symptomatic atopic dermatitis. When prick-test findings are positive, patients should be advised to avoid the culprit substances.

Sensitizing agents found in children and adolescents with recalcitrant atopic dermatitis: a cross-sectional study with a pediatric battery

BACKGROUND

Atopic dermatitis is the most common inflammatory skin disease in childhood and has an important impact on quality of life, especially severe cases or those that are recalcitrant to treatments. Sensitization to allergens with the potential for allergic contact dermatitis is a factor associated with cases of recalcitrant atopic dermatitis. Understanding the relationship between atopic dermatitis, allergens, and allergic contact dermatitis is essential. In Brazil, there are no studies on sensitization to allergens found in patch tests with pediatric batteries in patients with atopic dermatitis.

OBJECTIVES

To verify the main sensitizing agents, the prevalence of allergic contact dermatitis and the epidemiological and clinical profile of children and adolescents with atopic dermatitis.

METHODS

Cross-sectional, prospective study in patients between 4 and 18 years of age, with recalcitrant atopic dermatitis, treated at the Sanitary Dermatology Outpatient Clinic (RS). All patients underwent patch tests with a battery of pediatric allergens.

RESULTS

The prevalence of sensitization and allergic contact dermatitis in the evaluated patients was 37.07% (20/54) and 27.7% (15/54), respectively. The most frequent allergens were: nickel sulfate (16.7%), disperse blue (5.6%), and fragrance mix I (5.6%). Nickel was associated with the female sex (p = 0.019).

STUDY LIMITATIONS

Sample size and selection, absence of a control group.

CONCLUSIONS

A proportion of patients with recalcitrant atopic dermatitis may be sensitized to different allergens and may even have developed allergic contact dermatitis. Recognizing this context is important in the prevention strategy and management of the disease.

Contact allergy in children with and without atopic dermatitis: an Italian multicenter study

Background

Contact allergy and atopic dermatitis (AD) are both common inflammatory T cell‐mediated diseases and many factors may influence the prevalence of contact allergy in AD patients. In children, their possible correlation was debated with conflicting results.

Objectives

The present study aimed to assess the prevalence of contact sensitivity in children and to investigate the association with AD.

Materials and methods

A retrospective multicentre study on children aged from 0 to 14 years patch tested between January 2017 and December 2018 was performed. Children were consecutively patch tested with the SIDAPA (Società Italiana Dermatologia Allergologica Professionale Ambientale) baseline series.

Results

Among the 432 children investigated for contact allergy, 125 (28.9%) showed a positive reaction to at least one of the allergens tested, with a higher prevalence of positive patch test reactions in girls (32.3%) than in boys (25.0%). The most frequent contact allergens were nickel sulphate (10.2%), cobalt chloride (6.7%), methylisothiazolinone (3.7%), fragrance mix‐2 (3.2%), potassium dichromate (2.8%), fragrance mix‐1 (2.1%) and methylchloroisothiazolinone/methylisothiazolinone (2.1%). One‐hundred‐three children (23.8%) suffered from AD showing a higher prevalence of positive patch test (36.9%) compared to children without AD (26.4%).

Conclusions

Despite the topic being still controversial, the present study suggests a consistent prevalence of contact allergy among children with higher sensitivity rate among children with AD than without AD.

Global Burden, Incidence and Disability-Adjusted Life-Years for Dermatitis: A Systematic Analysis Combined With Socioeconomic Development Status, 1990–2019

Background

Dermatitis is an important global health problem that not only affects social interaction and physical and mental health but also causes economic burden. Health problems or distress caused by dermatitis may be easily overlooked, and relevant epidemiological data are limited. Therefore, a better understanding of the burden of dermatitis is necessary for developing global intervention strategies.

Methods

All data on dermatitis, including atopic dermatitis (AD), contact dermatitis (CD) and seborrhoeic dermatitis (SD), were obtained from the Global Burden of Disease 2019 (GBD2019) database. The extracted age-standardized incidence rates (ASIR) and disability-adjusted life-years (DALYs) rates (ASDR) data were analysed by stratification, including by sex, country or region, and sociodemographic index (SDI) indicators. Finally, we analysed the correlation between the global burden of dermatitis and socioeconomic development status.

Results

According to the GBD 2019 estimate, the ASIR and ASDR for the three major types of dermatitis in 2019 were 5244.3988 (95% CI 4551.7244–5979.3176) per 100,000 person-years and 131.6711 (95% CI 77.5876–206.8796) per 100,000 person-years. The ASIR and ASDR of atopic dermatitis, contact dermatitis and seborrhoeic dermatitis are: Incidence (95%CI,per 100,000 person-years), 327.91 (312.76-343.67), 3066.04 (2405.38-3755.38), 1850.44 (1706.25- 1993.74); DALYs (95%CI, per 100,000 person-years), 99.69 (53.09-167.43), 28.06 (17.62-41.78), 3.93 (2.24-6.25). In addition, among the three dermatitis types, the greatest burden was associated with AD. According to the ASDR from 1990 to 2019, the burden of dermatitis has exhibited a slow downward trend in recent years. In 2019, the ASIR showed that the USA had the greatest burden, while the ASDR showed that Asian countries (such as Japan, Mongolia, Kazakhstan, and Uzbekistan) and some European countries (France, Estonia) had the greatest burden. According to SDI stratification and the three major dermatitis types, high ASIR and ASDR corresponded to high SDI areas (especially for AD).

Conclusion

The burden of dermatitis is related to socioeconomic development status, especially for AD, which is positively correlated with the SDI. The results based on GBD2019 data are valuable for formulating policy, preventing and treating dermatitis and reducing the global burden of dermatitis.

What We Have Learned–Milestones in Pediatric Contact Dermatitis

Purpose of Review

This review highlights recent developments in the field of pediatric allergic contact dermatitis (ACD) and patch testing. We will review updates on the pathophysiology of contact dermatitis, discuss new contact allergens, explore the impact of dupilumab on patch testing, and provide pearls for the diagnosis and management of ACD in children.

Recent Findings

ACD is not a single immunologic phenomenon but rather has contributions from multiple inflammatory pathways. Emerging contact allergens include ingredients found in “slime” toys, glucose monitors and insulin pumps, and electronic equipment. Data thus far suggests that patch testing results are generally reliable in the face of concurrent dupilumab use.

Summary

ACD is likely underrecognized and underdiagnosed in pediatric patients, including infants and young children. Providers should keep patient-specific factors and emerging trends in mind when addressing suspected ACD, consider contact dermatitis when they encounter challenging cases of atypical, refractory, or chronic dermatitis, and feel comfortable performing patch testing in children.

Pattern of contact sensitisation in patients with and without atopic dermatitis in an Asian dermatology centre

BACKGROUND

Although the traditional understanding is that contact sensitisation is less frequent in atopic dermatitis (AD) patients, recent studies have shown similar or higher rates of positive patch test results in AD patients.

METHODS

This was a single-centre, ten-year retrospective review on contact sensitisation in patients who underwent patch testing between 2007 and 2017. The aims were to characterise the pattern of contact sensitisation and to ascertain a link between contact sensitisation and AD.

RESULTS

There were 4903 patients (males:females = 1:1.4; mean age 40.1 years old) included. About half (2499, 51.0%) of all patients developed at least one positive reaction. The top five frequent reactions were to nickel sulfate (45.4%), potassium dichromate (16.0%), p-phenylenediamine (13.4%), Myroxylon pereirae (11.8%) and fragrance mix I (11.2%). The overall prevalence of contact sensitisation was not significantly different between patients with or without AD. Patients with AD were less likely to develop contact allergies to budesonide and thiuram mix, and more likely to develop contact allergies to potassium dichromate.

CONCLUSIONS

Contact sensitisation was detected in 50% of patients patch-tested. Nickel sulfate was the most frequently sensitising allergen. The prevalence of contact allergies in atopic patients is comparable to that in non-atopic patients. This article is protected by copyright. All rights reserved.

Pediatric patch testing in a multi-ethnic Asian population: A retrospective review

BACKGROUND

Pediatric allergic contact dermatitis (ACD) is increasingly prevalent. Patch testing is the gold-standard diagnostic investigation. The aims of our study were to describe the clinical profile of pediatric patients with ACD in a multi-ethnic Asian population and identify the common contact allergens.

METHODS

This was a retrospective study involving children and adolescents aged 16 years or younger with clinically suspected ACD who underwent patch testing between January 2007 and March 2020 at two institutions in Singapore. Information pertaining to their demographics, atopy history, clinical presentation, and patch test results was analyzed.

RESULTS

A total of 252 patients were included. The mean age was 10.9 years (1.0-16.7 years). The majority were Chinese (79.8%) and girls (57.5%). Many (66.3%) had atopic dermatitis (AD), which was mild. The most common presentation was an acral eczematous rash. The sensitization rate was 50.0%. The most frequent reactions were to nickel sulfate (49.2%) and fragrance mix (19.1%). The overall rate of relevant positive patch tests was 72.5%. Patients with AD were less likely to have a reaction to fragrance mix (p = .019) and more likely to have a reaction to disperse blue (p = .041). Compared to younger children, adolescents were less likely to have a positive patch test (p = .008). Indians were also less likely to have a positive reaction (p = .004).

CONCLUSION

Metals and fragrances were the most common allergens causing childhood ACD in Singapore. Patients with AD were less likely to be sensitized to fragrances and more likely to be sensitized to disperse blue dye.

Patch Test Clinic Start-up: From Basics to Pearls

Allergic contact dermatitis is a prevalent burdensome condition affecting millions of Americans. Patch testing, the criterion-standard allergic contact dermatitis diagnostic tool, is underused by US dermatologists. Incorporating patch testing into modern dermatology practices is achievable with utilization of accurate resources and sustainable support. This review focuses on the basics of patch testing and provides practical pearls to assist novice providers in establishing a contact dermatitis specialty practice.

Contact Dermatitis: Classifications and Management

Contact dermatitis (CD) is a common inflammatory skin disease caused by exposure to contact allergens and irritants. It is also the most common reason of occupational dermatitis and contributes greatly to hand dermatitis and facial dermatitis. Besides the two major forms of contact dermatitis: allergic contact dermatitis and irritant contact dermatitis, other subtypes of CD have been recognized including immediate skin reactions, photoinduced contact dermatitis, systemic contact dermatitis, and non-eczematous contact dermatitis. CD is a great imitator which can mimic many kinds of skin diseases, such as atopic dermatitis, lichen planus, and angioedema. For the diagnosis of CD, a complete medical history, including occupational history, is very important. It can give a clue of CD and provide a list of suspected substances. Besides the well-known diagnostic test, patch testing, there are many other diagnostic tests can be used to help diagnosis of CD and identify the causative allergens, including photopatch test, skin tests for detecting of immediate contact reactions, serum allergen-specific IgE test, and qualitative and quantitative testing of allergen in the suspected materials patients exposed to and challenge test. Before the treatment, the suspected irritants or allergens should be avoided completely. This includes both the removal of the patient from the environment that contains those substances and the promotion of the metabolism and expulsion of the allergens that have been absorbed by the body. In addition, it is also important to restore the skin barrier and reduce skin inflammation through multiple treatments, such as emollients, topical corticosteroids, and antihistamines, as well as systemic corticosteroids and immunosuppressants. Early and appropriate treatments are important to prevent further deterioration and persistence of the skin condition.

Epidemics of Dermatitis

Allergic contact dermatitis (ACD) remains a globally prevalent disease for both children and adults. The silent ACD epidemic continues to be fueled by the introduction of novel allergens in industrial and household products and the continued presence of known allergens. In 1997, Allan Dillarstone noted a sinusoidal pattern to epidemics when allergenic preservatives were replaced by alternative chemicals within the market, which then similarly increased in allergenicity. A call for public health vigilance and prevention initiatives is needed to intervene in the ACD epidemic.

[Palmoplantar dermatoses in children]

Dermatoses of the hands and feet cover a wide range of skin diseases that can occur in children and adolescents and are a frequent question in dermatological practice. Our synopsis of the most important differential diagnoses and their treatment is intended to provide better orientation for daily practice. A precise and detailed history is essential to establish a diagnosis, followed by clinical examination and specific examination methods. Cutaneous infection should always be excluded, as they occur very frequently. Impetigo, punctate keratolysis, blistering distal dactylitis, tinea manuum and pedum, hand-foot-mouth disease, herpes simplex digitalis and verrucae vulgaris as well as scabies are often found in the palmoplantar area and typically affect children and adolescents. In case of allergic contact dermatitis and dyshidrotic eczema, atopic diathesis in the medical history is of importance. However, we must not miss rare causes. Palmoplantar keratoses, for example, can be due to inflammatory dermatoses like pityriasis rubra pilaris (PRP) or may, as well as blistering diseases, result from hereditary disorders. Specialised centers can perform molecular genetic diagnosis and enhance patient care.

Pediatric allergic contact dermatitis. Part I: Clinical features and common contact allergens in children

Allergic contact dermatitis (ACD), a delayed hypersensitivity skin reaction to environmental allergens, has a prevalence that is similar in children and adults. However, diagnostic testing for ACD in pediatric populations accounts for less than one tenth of all patch tests. The relative infrequency of pediatric patch testing may be attributed to the difficulty in testing in this population, which includes a smaller surface area for patch test placement and maintaining cooperation during patch testing, especially in younger children. Diagnosis can be difficult in children because the appearance of ACD can mimic other common pediatric skin conditions, particularly atopic dermatitis and irritant contact dermatitis. Comprehensive history taking, guided by patient presentation, age group, and location of dermatitis, helps build clinical suspicion. Such clinical suspicion is one of the major reasons behind patch testing, with additional indications being recalcitrant dermatitis and dermatitis with atypical distribution. US pediatric data have shown the top allergens to be metals, fragrances, topical antibiotics, preservatives, and emollients. These trends are important to recognize to guide management and accurate diagnosis, because ACD tends to persist if the allergen is not identified and can affect patients' quality of life.

Pediatric contact dermatitis: what's new

PURPOSE OF REVIEW

Allergic contact dermatitis (ACD) was once thought to be rare in children but recent studies have demonstrated that the prevalence of ACD is common and appears to be increasing in children. Current trends including toys, hobbies, and personal care products may play a role in potentially new allergen exposure or resurgence of certain allergens, making ACD a moving target in children.

RECENT FINDINGS

ACD and atopic dermatitis can coexist and certain clinical features can help differentiate ACD from endogenous atopic dermatitis in children. It is important to consider ACD in children with recalcitrant atopic dermatitis or dermatitis with atypical distribution. Patch testing has become a more common practice in children. In 2018, the first expert consensus-derived pediatric baseline series consisting of 38 allergens was proposed to aid in the diagnosis of ACD in children. Comparing recent patch testing data in the pediatric population, the top allergens ubiquitously identified were nickel, cobalt, neomycin, Myroxylon pereirae (balsam of Peru), fragrance mix I, fragrance mix II, methylisothiazolinone, methylchloroisothiazolinone/ methylisothiazolinone, formaldehyde, and lanolin.

SUMMARY

ACD is a common problem in children. Detection through patch testing, avoidance of offending allergens, and prevention of common allergens are the main focus of management of ACD in children.

Allergic Contact Dermatitis in Children: Recommendations for Patch Testing

PURPOSE OF REVIEW

Allergic contact dermatitis (ACD) affects 20% of children. However, diagnosis of ACD may be underreported in children due to lack of recognition. Patch testing is the gold standard for evaluation of ACD in children but poses unique challenges in this population.

RECENT FINDINGS

Recent studies highlight the significance of ACD and the utility of patch testing in children. Evaluation of ACD in children is difficult and requires knowledge of a child's exposure history, careful selection of allergens, and knowledge of specialized patch testing considerations to minimize irritation and maximize cooperation. Until recently, there were no agreed upon patch test series for children. In 2018, a comprehensive pediatric baseline series was published enabling thorough evaluation of ACD in children (Yu J, Atwater AR, Brod B, Chen JK, Chisolm SS, Cohen DE, et al. Dermatitis. 2018;29(4):206-12). This review provides an overview of the current literature, an update on pediatric ACD, and patch testing methods in children to effectively evaluate and manage ACD.

Consensus on the therapeutic management of atopic dermatitis - Brazilian Society of Dermatology

BACKGROUND

Atopic dermatitis is a highly prevalent inflammatory and pruritic dermatosis with a multifactorial etiology, which includes skin barrier defects, immune dysfunction, and microbiome alterations. Atopic dermatitis is mediated by genetic, environmental, and psychological factors and requires therapeutic management that covers all the aspects of its complex pathogenesis.

OBJECTIVES

The aim of this article is to present the experience, opinions, and recommendations of Brazilian dermatology experts regarding the therapeutic management of atopic dermatitis.

METHODS

Eighteen experts from 10 university hospitals with experience in atopic dermatitis were appointed by the Brazilian Society of Dermatology to organize a consensus on the therapeutic management of atopic dermatitis. The 18 experts answered an online questionnaire with 14 questions related to the treatment of atopic dermatitis. Afterwards, they analyzed the recent international guidelines on atopic dermatitis of the American Academy of Dermatology, published in 2014, and of the European Academy of Dermatology and Venereology, published in 2018. Consensus was defined as approval by at least 70% of the panel.

RESULTS/CONCLUSION

The experts stated that the therapeutic management of atopic dermatitis is based on skin hydration, topical anti-inflammatory agents, avoidance of triggering factors, and educational programs. Systemic therapy, based on immunosuppressive agents, is only indicated for severe refractory disease and after failure of topical therapy. Early detection and treatment of secondary bacterial and viral infections is mandatory, and hospitalization may be needed to control atopic dermatitis flares. Novel target-oriented drugs such as immunobiologicals are invaluable therapeutic agents for atopic dermatitis.