Systemic Contact Dermatitis

Acidic oral environment's potential contribution to palladium-induced systemic contact dermatitis: Case report

Acidic oral environments may trigger systemic contact dermatitis via ionization of metals, including palladium. A patch test revealed a late delayed positive response to palladium, emphasizing the need for nuanced diagnostic approaches for allergy management.

Systemic allergic dermatitis (systemic contact dermatitis) from pharmaceutical drugs: A review

The literature on systemic allergic dermatitis (SAD; also known as systemic contact dermatitis) is reviewed. Both topical drugs (from absorption through mucosae or skin) and systemic drugs (oral, parenteral, rectal) may be responsible for the disorder. The topical route appears to be rare with 41 culprit topical drugs found to cause SAD in 95 patients. Most reactions are caused by budesonide (especially from inhalation), bufexamac, and dibucaine. SAD from systemic drugs is infrequent with 95 culprit drugs found to cause SAD in 240 patients. The drugs most frequently implicated are mitomycin C, methylprednisolone (salt, ester), and hydrocortisone (salt). The largest group of culprit drugs consisted of corticosteroids (19%), being responsible for >30% of the reactions, of which nearly 40% were not caused by therapeutic drugs, but by drug provocation tests. The most frequent manifestations of SAD from drugs are eczematous eruptions (scattered, widespread, generalized, worsening, reactivation), maculopapular eruptions, symmetrical drug-related intertriginous and flexural exanthema (SDRIFE [baboon syndrome]) and widespread erythema or erythroderma. Therapeutic systemic drugs hardly ever cause reactivation of previously positive patch tests and infrequently of previous allergic contact dermatitis. The pathophysiology of SAD has received very little attention. Explanations for the rarity of SAD are suggested.

Systemic Contact Dermatitis: The Routes of Allergen Entry

Systemic contact dermatitis (SCD) is a generalized reactivation of type IV hypersensitivity skin diseases in individuals with previous sensitization after a contact allergen is administered systemically. Patients with SCD may consider their dermatitis unpredictable and recalcitrant since the causative allergens are difficult to find. If a patient has a pattern of dermatitis suggestive of SCD but fails to improve with conventional treatment, SCD should be taken into consideration. If doctors are not familiar with the presentations of SCD and the possible routes of allergen sensitization and exposure, the diagnosis of SCD may be delayed. In this work, we summarized all of the routes through which allergens can enter the body and cause SCD, including oral intake, local contact (through skin, inhalation, nasal spray and anal application), implants, and other iatrogenic or invasive routes (intravenous, intramuscular, intraarticular, and intravesicular). This will provide a comprehensive reference for the clinicians to identify the culprit of SCD.

Environmental Causes of Dermatitis

Environmental, or exogenous, dermatitis is comprised of irritant and allergic contact dermatitis, which account for 80% and 20% of cases of contact dermatitis, respectively. Contact dermatitis is extremely common, and failure to diagnose this entity may result in overlooking a potentially curable driver of disease. In this review, we describe how clinical features, such as morphology or history, can assist in distinguishing exogenous from endogenous causes of dermatitis, and allergic from irritant contact dermatitis. Additionally, we provide an overview of common contact allergens and how dermatitis distribution can suggest possible culprit allergens. Patch testing is needed to confirm contact allergy.

Nickel Sensitivity Is Associated with GH-IGF1 Axis Impairment and Pituitary Abnormalities on MRI in Overweight and Obese Subjects

Nickel (Ni) is a ubiquitous metal, the exposure of which is implied in the development of contact dermatitis (nickel allergic contact dermatitis (Ni-ACD)) and Systemic Ni Allergy Syndrome (SNAS), very common among overweight/obese patients. Preclinical studies have linked Ni exposure to abnormal production/release of Growth Hormone (GH), and we previously found an association between Ni-ACD/SNAS and GH-Insulin-like growth factor 1 (IGF1) axis dysregulation in obese individuals, altogether suggesting a role for this metal as a pituitary disruptor. We herein aimed to directly evaluate the pituitary gland in overweight/obese patients with signs/symptoms suggestive of Ni allergy, exploring the link with GH secretion; 859 subjects with overweight/obesity and suspected of Ni allergy underwent Ni patch tests. Among these, 106 were also suspected of GH deficiency (GHD) and underwent dynamic testing as well as magnetic resonance imaging for routine follow up of benign diseases or following GHD diagnosis. We report that subjects with Ni allergies show a greater GH-IGF1 axis impairment, a higher prevalence of Empty Sella (ES), a reduced pituitary volume and a higher normalized T2 pituitary intensity compared to nonallergic ones. We hypothesize that Ni may be detrimental to the pituitary gland, through increased inflammation, thus contributing to GH-IGF1 axis dysregulation.

Contact Dermatitis to Carmine

: Carmine is a widely used "natural" food additive that has been reported to provoke both an immediate hypersensitivity and a delayed systemic response with cutaneous expression. Systemic contact dermatitis describes the hypersensitivity reaction following systemic re-exposure of the inciting allergen in previously sensitized individuals. In individuals with recalcitrant dermatitis and a positive carmine intolerance history and/or patch test, it is important to consider a trial topical and dietary elimination of carmine-associated products and foods.

Overweight and obese patients with nickel allergy have a worse metabolic profile compared to weight matched non-allergic individuals

Background

A lack of balance between energy intake and expenditure due to overeating or reduced physical activity does not seem to explain entirely the obesity epidemic we are facing, and further factors are therefore being evaluated. Nickel (Ni) is a ubiquitous heavy metal implied in several health conditions. Regarding this, the European Food Safety Authority has recently released an alert on the possible deleterious effects of dietary Ni on human health given the current levels of Ni dietary intake in some countries. Pre-clinical studies have also suggested its role as an endocrine disruptor and have linked its exposure to energy metabolism and glucose homeostasis dysregulation. Ni allergy is common in the general population, but preliminary data suggest it being even more widespread among overweight patients.

Objectives

The aim of this study has been to evaluate the presence of Ni allergy and its association with the metabolic and endocrine profile in overweight and obese individuals.

Methods

We have evaluated 1128 consecutive overweight and obese outpatients. 784 were suspected of being allergic to Ni and 666 were assessed for it. Presence of Ni allergy and correlation with body mass index (BMI), body composition, metabolic parameters and hormonal levels were evaluated.

Results

We report that Ni allergy is more frequent in presence of weight excess and is associated with worse metabolic parameters and impaired Growth Hormone secretion.

Conclusions

We confirm that Ni allergy is more common in obese patients, and we report for the first time its association with worse metabolic parameters and impaired function of the GH-IGF1 axis in human subjects.

MD-2 determinants of nickel and cobalt-mediated activation of human TLR4

Recent findings unexpectedly revealed that human TLR4 can be directly activated by nickel ions. This activation is due to the coordination of nickel by a cluster of histidine residues on the ectodomain of human TLR4, which is absent in most other species. We aimed to elucidate the role of MD-2 in the molecular mechanism of TLR4/MD-2 activation by nickel, as nickel binding site on TLR4 is remote from MD-2, which directly binds the endotoxin as the main pathological activator of TLR4. We identified MD-2 and TLR4 mutants which abolished TLR4/MD-2 receptor activation by endotoxin but could nevertheless be significantly activated by nickel, which acts in synergy with LPS. Human TLR4/MD-2 was also activated by cobalt ions, while copper and cadmium were toxic in the tested concentration range. Activation of TLR4 by cobalt required MD-2 and was abolished by human TLR4 mutations of histidine residues at positions 456 and 458. We demonstrated that activation of TLR4 by nickel and cobalt ions can trigger both the MyD88-dependent and the -independent pathway. Based on our results we propose that predominantly hydrophobic interactions between MD-2 and TLR4 contribute to the stabilization of the TLR4/MD-2/metal ion complex in a conformation that enables activation.

MD-2 determinants of nickel and cobalt-mediated activation of human TLR4

Recent findings unexpectedly revealed that human TLR4 can be directly activated by nickel ions. This activation is due to the coordination of nickel by a cluster of histidine residues on the ectodomain of human TLR4, which is absent in most other species. We aimed to elucidate the role of MD-2 in the molecular mechanism of TLR4/MD-2 activation by nickel, as nickel binding site on TLR4 is remote from MD-2, which directly binds the endotoxin as the main pathological activator of TLR4. We identified MD-2 and TLR4 mutants which abolished TLR4/MD-2 receptor activation by endotoxin but could nevertheless be significantly activated by nickel, which acts in synergy with LPS. Human TLR4/MD-2 was also activated by cobalt ions, while copper and cadmium were toxic in the tested concentration range. Activation of TLR4 by cobalt required MD-2 and was abolished by human TLR4 mutations of histidine residues at positions 456 and 458. We demonstrated that activation of TLR4 by nickel and cobalt ions can trigger both the MyD88-dependent and the -independent pathway. Based on our results we propose that predominantly hydrophobic interactions between MD-2 and TLR4 contribute to the stabilization of the TLR4/MD-2/metal ion complex in a conformation that enables activation.

Nickel sensitization and dietary nickel are a substantial cause of symptoms provocation in patients with chronic allergic-like dermatitis syndromes

Data in literature seem to show that, in patients with contact allergic dermatitis, dietary nickel might be a cause of systemic dermatitis, but little information exists in literature about the role of nickel sensitization and dietary nickel in patients with allergic-like chronic dermatitis syndromes. The prevalence of nickel sensitization in patients with chronic allergic-like, non-IgE-mediated skin diseases, and the possible impact of dietary nickel on symptom provocation and persistence has been assessed in the present retrospective study on a case series of 1726 patients referred to our allergy unit for chronic allergic-like skin diseases. IgE-mediated pathogenesis and other differential diagnoses excluded, patients were patch tested. Nickel-positive patients underwent an elimination diet and double-blind placebo-controlled nickel challenge (DBPCNC) test. A total of 339 (20%) tested nickel-positive. Fifty-two patients (15%) recovered by avoiding sources of nickel contact and 29 (10%) dropped out. Out of the remaining nickel-sensitized patients, 277 (80%) achieved complete or near complete recovery with low-nickel content diet, and 185 of them (89%) were positive to DBPCNC. We conclude that nickel sensitization and dietary nickel seem to be the chief trigger for provocation and persistence of symptoms in an important part (∼11%) of patients with chronic allergic-like dermatitis syndromes.

Allergic contact dermatitis in children: review of the past decade

Allergic contact dermatitis (ACD) is a type IV delayed hypersensitivity reaction. During the last decade, there has been a heightened awareness of this disease in the pediatric population. The gold standard for diagnosis is patch testing. The prevalence of positive patch tests in referred children with suspected ACD ranges from 27 to 95.6 %. The most common allergens in children in North America are nickel, neomycin, cobalt, fragrance, Myroxylon pereirae, gold, formaldehyde, lanolin/wool alcohols, thimerosal, and potassium dichromate. The relationship between ACD and atopic dermatitis (AD) is complicated with conflicting reports of prevalence in the literature; however, in a patient with dermatitis not responding to traditional therapies, or with new areas of involvement, ACD should be considered as part of the work-up.

Nickel and human health

This review focuses on the impact of nickel on human health. In particular, the dual nature of nickel as an essential as well as toxic element in nature is described, and the main forms of nickel that can come in contact with living systems from natural sources and anthropogenic activities are discussed. Concomitantly, the main routes of nickel uptake and transport in humans are covered, and the potential dangers that nickel exposure can represent for health are described. In particular, the insurgence of nickel-derived allergies, nickel-induced carcinogenesis as well as infectious diseases caused by human pathogens that rely on nickel-based enzymes to colonize the host are reviewed at different levels, from their macroscopic aspects on human health to the molecular mechanisms underlying these points. Finally, the importance of nickel as a beneficial element for human health, especially being essential for microorganisms that colonize the human guts, is examined.

The many faces of nickel allergy

Hypersensitivity reactions to nickel are one of the most common in the modern world. Nickel allergy prevalence is constantly growing in many countries and represents a major health and socioeconomic issue. Herein the current understanding on nickel allergy is summarized with a practical approach to the dermatologist, allergist, and general practitioner. The personal experience with some practical clinical cases of nickel dermatitis is shared. A special emphasis is put on the possible strategies for treatment and prevention of the disease.

Metal allergy and systemic contact dermatitis: an overview

Contact dermatitis is produced by external skin exposure to an allergen, but sometimes a systemically administered allergen may reach the skin and remain concentrated there with the aid of the circulatory system, leading to the production of systemic contact dermatitis (SCD). Metals such as nickel, cobalt, chromium, and zinc are ubiquitous in our environment. Metal allergy may result in allergic contact dermatitis and also SCD. Systemic reactions, such as hand dermatitis or generalized eczematous reactions, can occur due to dietary nickel or cobalt ingestion. Zinc-containing dental fillings can induce oral lichen planus, palmoplantar pustulosis, and maculopapular rash. A diagnosis of sensitivity to metal is established by epicutaneous patch testing and oral metal challenge with metals such as nickel, cobalt, chromium, and zinc. In vitro tests, such as the lymphocyte stimulating test (LST), have some advantages over patch testing to diagnose allergic contact dermatitis. Additionally, the determination of the production of several cytokines by primary peripheral blood mononuclear cell cultures is a potentially promising in vitro method for the discrimination of metal allergies, including SCD, as compared with the LST.

Systemic contact dermatitis

Systemic contact dermatitis is an inflammatory skin disease that may occur in persons with contact allergy when they are exposed to the hapten orally, transcutaneously, per rectum, intravesically, intravenously, or by inhalation. The most common causes of systemic contact dermatitis are drugs used both topically and systemically. Other causes are ubiquitously occurring haptens, such as the metals nickel, cobalt, gold, and chromate, and aromatic substances such as spices. Avoidance of the offending hapten is the most obvious treatment. For some haptens, such as nickel, diet treatment may be effective. Chelation therapy with disulfiram is another therapeutic option in nickel-allergic patients with systemic contact dermatitis. Hyposensitization therapy has been attempted with some success in systemic contact dermatitis caused by nickel and Parthenium hysterophorus.

Systemic contact dermatitis in children: how an avoidance diet can make a difference

Systemic contact dermatitis is an under-recognized skin reaction that occurs secondary to systemic (oral, intravenous, intramuscular, inhaled, or subcutaneous) exposure to a hapten in a previously sensitized individual. Medicaments are the most common cause of SCD in the adult population, but other chemicals like nickel, cobalt, balsam of Peru, and formaldehyde have been implicated as well. Few reports in children exist to date. Dietary restriction has shown to be of some benefit in managing some adult patients. We present a case series of 8 pediatric patients diagnosed with SCD from the contact dermatology clinic, who showed marked improvement of their dermatitis after adequate dietary avoidance. We review common presentations of chemicals causing SCD in children and potential dietary modifications.

Contact allergy and human biomonitoring--an overview with a focus on metals

Humans are widely exposed to chemicals. Today, there is an increased acknowledgement of the importance of measuring human and environmental exposures to man-made or refined chemicals. Different approaches have been applied over time, but during the past 25 years, there has been a general trend towards the use of human biomonitoring. A few studies have used human biomonitoring methodology to track contact allergens together with information on patch test reactivity. Hypothetically, the internal load of reactive chemicals might modify the immune response to haptens and the propensity to sensitize and elicit allergic contact dermatitis or develop tolerance. This review offers a general overview of human biomonitoring, including information about its typical application and methodology. Furthermore, studies that have attempted to perform simultaneous biomonitoring and patch testing are reviewed. It is concluded that all studies conducted until the present have focused on one or two routes of exposure (typically skin and oral exposure, but also skin and airway exposure), whereas no studies have investigated all routes at the same time. Also, there is a need for prospective studies, as all epidemiological studies so far have been cross-sectional.

Erythema multiforme-like irritant contact dermatitis after application of an antiscabies treatment

We describe the case of an irritant contact dermatitis due to an antiscabies treatment in a man who presented to our clinic with an important cutaneous reaction with many hemorrhagic, "target" erythema multiforme-like lesions, as the result of an acute toxic insult of the skin by permethrin 5%. This is a possible, but very uncommon symptom of non-eczematous contact dermatitis and an unusual drug causing the acute hypersensitivity reaction typical of erythema multiforme.

Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel

Food allergy is an important public health problem that affects children and adults and may be increasing in prevalence. Despite the risk of severe allergic reactions and even death, there is no current treatment for food allergy: the disease can only be managed by allergen avoidance or treatment of symptoms. The diagnosis and management of food allergy also may vary from one clinical practice setting to another. Finally, because patients frequently confuse nonallergic food reactions, such as food intolerance, with food allergies, there is an unfounded belief among the public that food allergy prevalence is higher than it truly is. In response to these concerns, the National Institute of Allergy and Infectious Diseases, working with 34 professional organizations, federal agencies, and patient advocacy groups, led the development of clinical guidelines for the diagnosis and management of food allergy. These Guidelines are intended for use by a wide variety of health care professionals, including family practice physicians, clinical specialists, and nurse practitioners. The Guidelines include a consensus definition for food allergy, discuss comorbid conditions often associated with food allergy, and focus on both IgE-mediated and non-IgE-mediated reactions to food. Topics addressed include the epidemiology, natural history, diagnosis, and management of food allergy, as well as the management of severe symptoms and anaphylaxis. These Guidelines provide 43 concise clinical recommendations and additional guidance on points of current controversy in patient management. They also identify gaps in the current scientific knowledge to be addressed through future research.

Systemic contact dermatitis from propolis ingestion

Propolis, also known as bee glue, is a substance collected by worker bees and it is used as a material for constructing and maintaining their beehives. It has been used topically and orally by humans for its anti-inflammatory properties. However, the growing use of propolis has been paralleled by reports of allergic contact dermatitis as a reaction to the substance. Contact dermatitis with generalized cutaneous manifestations elicited by propolis ingestion has not been previously reported. Here we report on the first case of systemic contact dermatitis from propolis ingestion in a 36-year-old woman.

Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel

Food allergy is an important public health problem that affects children and adults and may be increasing in prevalence. Despite the risk of severe allergic reactions and even death, there is no current treatment for food allergy: the disease can only be managed by allergen avoidance or treatment of symptoms. The diagnosis and management of food allergy also may vary from one clinical practice setting to another. Finally, because patients frequently confuse nonallergic food reactions, such as food intolerance, with food allergies, there is an unfounded belief among the public that food allergy prevalence is higher than it truly is. In response to these concerns, the National Institute of Allergy and Infectious Diseases, working with 34 professional organizations, federal agencies, and patient advocacy groups, led the development of clinical guidelines for the diagnosis and management of food allergy. These Guidelines are intended for use by a wide variety of health care professionals, including family practice physicians, clinical specialists, and nurse practitioners. The Guidelines include a consensus definition for food allergy, discuss comorbid conditions often associated with food allergy, and focus on both IgE-mediated and non-IgE-mediated reactions to food. Topics addressed include the epidemiology, natural history, diagnosis, and management of food allergy, as well as the management of severe symptoms and anaphylaxis. These Guidelines provide 43 concise clinical recommendations and additional guidance on points of current controversy in patient management. They also identify gaps in the current scientific knowledge to be addressed through future research.