Contact dermatitis: a practice parameter-update 2015

Potential for Glove Risk Amplification via Direct Physical, Chemical, and Microbiological Contamination

This review focuses on the potential direct physical, chemical, and microbiological contamination from disposable gloves when utilized in food environments, inclusive of the risks posed to food products as well as worker safety. Unrecognized problems endemic to glove manufacturing were magnified during the COVID-19 pandemic due to high demand, increased focus on PPE performance, availability, supply chain instability, and labor shortages. Multiple evidence-based reports of contamination, toxicity, illness, deaths, and related regulatory action linked to contaminated gloves in food and healthcare have highlighted problems indicative of systemic glove industry shortcomings. The glove manufacturing process was diagramed with sources and pathways of contamination identified, indicating weak points with documented occurrences detailed. Numerous unsafe ingredients can introduce chemical contaminants, potentially posing risks to food and to glove users. Microbial hazards present significant challenges to overall glove safety as contaminants appear to be introduced via polluted water sources or flawed glove manufacturing processes, resulting in increased risks within food and healthcare environments. Frank and opportunistic pathogens along with food spoilage organisms can be introduced to foods and wearers. When the sources and pathways of glove-borne contamination were explored, it was found that physical failures play a pivotal role in the release of sweat build-up, liquefaction of chemical residues, and incubation of microbial contaminants from hands and gloves. Thus, with glove physical integrity issues, including punctures in new, unused gloves that can develop into significant rips and tears, not only can direct physical food contamination occur but also chemical and microbiological contamination can find their way into food. Enhanced regulatory requirements for Acceptable Quality Limits of food-grade gloves, and the establishment of appropriate bioburden standards would enhance safety in food applications. Based on the information provided, together with a false sense of security associated with glove use, the unconditional belief in glove chemical and microbiological purity may be unfounded.

Clinical relevance of doubtful reactions in patch testing: A single-centre retrospective study

BACKGROUND

Doubtful reactions in patch testing are infrequently reported in the literature; however, recent reports have suggested they be assessed with the same scrutiny as stronger reactions.

OBJECTIVE

Assess the clinical relevance of doubtful reactions in patch testing.

METHODS

Retrospective study of 1514 patients comprehensively patch tested via the NACDG standard series and additional allergens based on history. The clinical relevance of each reaction was graded based on the NACDG scale: definite, probable, possible, past, unknown and irritant. Reactions were considered 'unique' if an additional mild-to-strong reaction to the same chemical at a different concentration was not observed.

RESULTS

68.9% (1043) of patients demonstrated at least 1 doubtful reaction. Of 4453 total doubtful reactions, 92.2% (4106) were unique. Only 3.3% (137) and 12.2% (500) of these were determined to be of definite or probable clinical relevance respectively. 'Fragrance' was the most common allergen family present among the unique definite doubtful reactions (37). However, 24 (64.9%) of these also had a stronger reaction to another fragrance. Cocamidopropyl betaine was the second most frequent allergen demonstrating definite doubtful reactions (27) and unique in 85.2% (23) of cases. Methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) was most prevalent (36) but less frequently unique (58.3%, 21).

CONCLUSIONS

Doubtful reactions may not be as impactful to clinical decision making as theorised in the literature. Few demonstrate definite clinical significance, and many have related stronger reactions that capture them for clinical purposes. Identification of doubtful reactions to cocamidopropyl betaine and MCI/MI may be of greatest significance as they most frequently were not supported by stronger reactions.

Global Guidelines in Dermatology Mapping Project (GUIDEMAP)-A systematic review of the methodological quality of contact dermatitis clinical practice guidelines

The Global Guidelines in Dermatology Mapping Project (GUIDEMAP) assesses the methodological quality of clinical practice guidelines (CPGs) for high-burden skin diseases. This review focuses on contact dermatitis. We searched MEDLINE, Embase, PubMed, Web of Science, Cochrane Library, Emcare, Epistemonikos, PsycINFO and Academic Search Premier for CPGs published between 1 November 2018 and 1 November 2023. Prespecified guideline resources were hand searched. Two authors independently undertook screening, data extraction and quality assessments. Instruments used were the Appraisal of Guidelines for Research and Evaluation (AGREE) II Reporting Checklist, the U.S. Institute of Medicine's (IOM) criteria of trustworthiness, The Agency for Healthcare Research and Quality's National Guideline Clearinghouse Extent Adherence to Trustworthy Standards (NEATS) Instrument and Lenzer's Red Flags. Twenty five CPGs were included, exhibiting heterogeneity in both the topics they addressed and their methodological quality. Whereas the CPGs on management of hand eczema from Denmark, Europe and the Netherlands scored best, most CPGs fell short of being clear, unbiased, trustworthy and evidence-based. Disclosure of conflicts of interest scored well, and areas needing improvement include 'strength and wording of recommendations', 'applicability', 'updating' and 'external review'. Adhering to AGREE II and Grading of Recommendations, Assessment, Development and Evaluations (GRADE) enhances methodological quality.

Metal implant allergy: A retrospective cohort analysis at a university allergy practice

Background: Concern of metal sensitization in pre- and postsurgical evaluation is growing, with the recent guidelines remaining the criterion standard for consideration of patch testing. Information remains scarce on surgical screening in the groups of patients who reported a history of metal sensitivity versus those with no reported history. Objective: The objective of this study was to assess the utility of patch testing in surgical candidates based on reported metal allergy history. The secondary objective was to evaluate the utility and outcomes in postsurgical patch testing. Methods: Nine hundred and thirty-one patient charts of patients with the diagnosis of "contact dermatitis" who underwent an evaluation at a single allergy clinic site between January 2013 and December 2022 were identified and reviewed as part of a retrospective chart review study. Patients were included in subgroups based on the time of patch testing and history of reported metal allergy. Results: In all, 67 patients underwent patch testing, 10 (14.9%) of whom were surgical candidates without a history of metal sensitivity, 31 (46.2%) of whom were surgical candidates with a history of metal sensitivity, and 26 (38.8%) of whom were postsurgical patients. Twenty-nine (43.3%) of patients had positive patch testing results, with only one (10%) in the presurgical group, 17 (54.8%) in the presurgical with a history of metal sensitivity, and 11 (42.3%) in the postsurgical group. Zero patients in our cohort without metal sensitivity who were undergoing the Nuss procedure had positive reactions on patch testing, whereas two of four (50%) with reported metal sensitivity who were undergoing the Nuss procedure had positive relevant metal reactions. Conclusion: Ambiguity in the utility of patch testing for surgical decision making remains, despite common utilization. Recent guidelines along with coordination of care among the surgeon, allergist, and patient remains the criterion standard of care.

Allergic or Not: Final Interpretation of Doubtful Patch Test Reactions From the North American Contact Dermatitis Group, 2019-2020

Background: Doubtful patch test reactions generally do not meet criterion for positivity in patch testing. However, the North American Contact Dermatitis Group (NACDG) allows for doubtful reactions to be coded with a final determination of "allergic/positive" based on the temporal pattern, appearance, known characteristics of the allergen, and/or other supportive patch test reactions. Objectives: To analyze NACDG data from the 2019-2020 patch test cycle to identify patterns in the interpretation and relevance of doubtful reactions. Methods: The frequency and proportions of doubtful reactions were tabulated and analyzed for patterns. Statistical analyses were limited to allergens with ≥30 doubtful reactions to ensure adequate sample size. Results: Of patch-tested patients, 31.9% (1315/4121) had ≥1 doubtful reaction. Of 2538 total doubtful reactions, 46% (n = 1167) had a final interpretation of "allergic/positive." The allergens with the highest proportion of doubtful reactions at the final visit were hydroperoxides of linalool 1% (4.5%), fragrance mix I 8.0% (3.9%), and cetrimonium chloride 0.5% (3.4%). Methylchloroisothiazolinone/methylisothiazolinone (MCI/MI) 0.02% (P < 0.001), MI 0.2% (P < 0.001), nickel sulfate hexahydrate 2.5% (P = 0.001), and neomycin sulfate 20.0% (P = 0.003) doubtful reactions were more likely to be interpreted as allergic than nonallergic. Methyldibromoglutaronitrile/phenoxyethanol 0.2% (P < 0.001), oleamidopropyl dimethylamine 0.1% (P < 0.001), formaldehyde 2.0% (P < 0.001), cetrimonium chloride 0.5% (P < 0.001), benzophenone-4 (sulisobenzone) 10% (P < 0.001), iodopropynyl butylcarbamate 0.5% (P < 0.001), cocamidopropyl betaine 1.0% (P = 0.002), and benzisothiazolinone 0.1% (P = 0.012) doubtful reactions were less likely to be interpreted as allergic. Of the 1167 doubtful reactions interpreted as allergic, 84.9% had current relevance. Conclusions: Doubtful reactions were common and approximately one half were coded with a final interpretation of "allergic/positive." Of those, most were clinically relevant. MCI/MI, MI, nickel, and neomycin were more likely to be interpreted as allergic.

Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations

BACKGROUND

Guidance addressing atopic dermatitis (AD) management, last issued in 2012 by the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force, requires updating as a result of new treatments and improved guideline and evidence synthesis methodology.

OBJECTIVE

To produce evidence-based guidelines that support patients, clinicians, and other decision-makers in the optimal treatment of AD.

METHODS

A multidisciplinary guideline panel consisting of patients and caregivers, AD experts (dermatology and allergy/immunology), primary care practitioners (family medicine, pediatrics, internal medicine), and allied health professionals (psychology, pharmacy, nursing) convened, prioritized equity, diversity, and inclusiveness, and implemented management strategies to minimize influence of conflicts of interest. The Evidence in Allergy Group supported guideline development by performing systematic evidence reviews, facilitating guideline processes, and holding focus groups with patient and family partners. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach informed rating the certainty of evidence and strength of recommendations. Evidence-to-decision frameworks, subjected to public comment, translated evidence to recommendations using trustworthy guideline principles.

RESULTS

The panel agreed on 25 recommendations to gain and maintain control of AD for patients with mild, moderate, and severe AD. The eAppendix provides practical information and implementation considerations in 1-2 page patient-friendly handouts.

CONCLUSION

These evidence-based recommendations address optimal use of (1) topical treatments (barrier moisturization devices, corticosteroids, calcineurin inhibitors, PDE4 inhibitors [crisaborole], topical JAK inhibitors, occlusive [wet wrap] therapy, adjunctive antimicrobials, application frequency, maintenance therapy), (2) dilute bleach baths, (3) dietary avoidance/elimination, (4) allergen immunotherapy, and (5) systemic treatments (biologics/monoclonal antibodies, small molecule immunosuppressants [cyclosporine, methotrexate, azathioprine, mycophenolate, JAK inhibitors], and systemic corticosteroids) and UV phototherapy (light therapy).

Silk Bioprotein as a Novel Surgical-Site Wound Dressing: A Prospective, Randomized, Single-Blinded, Superiority Clinical Trial

Background

Medical adhesive-related skin injuries (MARSIs) affect about 1.5 million patients annually in the United States. Complications include allergic contact dermatitis, skin blistering, skin tears, and surgical-site infections (SSIs). The authors hypothesize that a natural hypoallergenic silk bioprotein wound dressing will decrease the incidence of MARSI in comparison to a synthetic alternative.

Objectives

This study aimed to assess the efficacy and safety of a silk bioprotein wound dressing compared to the Dermabond Prineo (Ethicon, Inc., Somerville, NJ) skin closure system.

Methods

This prospective, randomized, single-blinded trial studied 25 patients who were dressed with Dermabond Prineo on one side of their body and on the contralateral side with the silk bioprotein dressing after undergoing abdominoplasty or reduction mammaplasty procedures. Data were collected over 5 postoperative visits using photographs and an investigator administered questionnaire to track rash, itch, discomfort, erythema, edema, SSIs, need for pharmaceutical intervention, mechanical injury, removal time, and bathing routines.

Results

Sixty-four percent (16/25) of patients characterized the severity of discomfort as a score of 4 out of 10 or greater on the Dermabond Prineo control side and only 4% (1/25) for the silk-dressing side (P < .001). Fifty-two percent (13/25) had a visible rash of 4 or higher on the Dermabond Prineo side of their incision and 0% (0/25) had a rash on the silk side (P < .001). Fifty-two percent (13/25) required steroids or antibiotics to treat MARSI to Dermabond Prineo and 0% (0/25) required pharmaceutical intervention on the silk side (P < .001).

Conclusions

The use of a silk bioprotein wound dressing significantly reduces the incidence of MARSI throughout the postoperative period.

Level of Evidence 2

Diseases from the Spectrum of Dermatitis and Eczema: Can "Omics" Sciences Help with Better Systematics and More Accurate Differential Diagnosis?

Researchers active in the field of inflammatory skin diseases from the spectrum of dermatitis and eczema are well aware of a considerable overlap in the clinical pictures and proposed sets of diagnostic criteria for these diseases, which can hardly be overcome through the clinical or epidemiological research. In effect, patients are included in studies based on vague and overlapping criteria, while heterogeneous study populations may, in turn, lead to non-representative outcomes and continued confusion. In this narrative review, a systematics of diseases from the spectrum of dermatitis and eczema is proposed based on the origins of causative factors and the pathomechanisms involved. Difficulties in differentiating between these diseases are discussed, and the extent to which advances in the "omics" sciences might help to overcome them is considered. Of all the "omics" research in this field, more than 90% of the published papers were devoted to atopic dermatitis, with a striking underrepresentation of other diseases from the spectrum of dermatitis and eczema, conditions which collectively exceed the rates of atopic dermatitis by far. A greater "omics" research effort is urgently needed to tackle other dermatitides, like allergic, irritant and protein contact dermatitis, as well as radiation, seborrheic, stasis or autoimmune dermatitis. Atopic dermatitis findings should be validated not only against healthy donors but also other dermatitides. A clinic-oriented approach is proposed for future "omics" studies in the field of dermatitis and eczema.

Allergy to Local Anesthetics is a Rarity: Review of Diagnostics and Strategies for Clinical Management

Local anesthetics (LA) are commonly used in procedures and in topical agents for pain management. With the increasing use of LA drugs, the management of LA reactions is more frequently encountered in the office and in operating rooms. True allergic reactions involving IgE-mediated reactions and anaphylaxis are rare; they have only been identified in case reports and account for less than 1% of adverse LA reactions. Most reactions are non-allergic or are a result of hypersensitivity to other culprits such as preservatives, excipients, or other exposures. LA reactions that are misclassified as true allergies can lead to unnecessary avoidance of LA drugs or delays in surgical procedures that require their use. A detailed history of prior LA reactions is the first and most crucial step for understanding the nature of the reaction. Reactions that are suspicious for an immediate hypersensitivity reaction can be evaluated with skin prick and intradermal testing with subsequent graded challenge. Reactions that are suspicious for a delayed hypersensitivity reaction can be evaluated with patch testing.

2-Octyl cyanoacrylate, a hidden allergen, a common cause of postsurgical allergic contact dermatitis

Background: 2-Octyl cyanoacrylate, a topical adhesive used for wound closure, is becoming a common cause for rashes in postsurgical patients. There is an increased number of cases of postsurgical contact dermatitis attributable to 2-octyl cyanoacrylate. Localized skin reactions to 2-octyl cyanoacrylate have been described in different case reports, but there are limited case reports of diffuse cutaneous allergic reactions. Objective: The aim of the study was to review our experience in patch testing with cyanoacrylates. Methods: We reported five cases of allergic contact dermatitis to 2-octyl cyanoacrylate, confirmed by a patch test. All the patients experienced a skin reaction a few days after surgery. The patients described an erythematous pruritic rash initially localized over the incision and that subsequently spread to surrounding areas. Two of the five patients developed a more widespread rash, which required a longer duration of systemic steroids. 2-Octyl cyanoacrylate remains an agent of low diagnostic suspicion as the possible cause of contact dermatitis after a surgical procedure. Results: All the patients, but one had a positive reaction to 2-octyl cyanoacrylate on PT. Four had a positive PT result, with one patient having a positive scratch test after a negative PT result. Testing on abraded skin further increased yield. Conclusion: Postsurgical patients should be evaluated by using a patch test if there is a clinical picture suggestive of contact dermatitis.

Allergic Contact Cell-Mediated Hypersensitivity in Psoriasis: A Narrative Minireview

The dysfunctionality of the protective skin barrier in psoriasis allows easier cutaneous penetration of various contact haptens; thus, such patients can develop allergic contact hypersensitivity as a comorbidity. Both skin conditions involve T-cell-mediated mechanisms. Dermatologists and allergists should consider assessing allergic contact cell-mediated hypersensitivity in selected psoriasis patients, especially those with palmoplantar psoriasis and who are refractory to topical treatments, and in patients with psoriasis, with or without arthritis, treated with biologics that present skin lesions clinically suggestive of contact dermatitis.

Contact allergens for the allergist

OBJECTIVE

The objective of this article is to provide an overview and describe typically encountered skin contact allergens implicated in allergic contact dermatitis (ACD).

DATA SOURCES

Published literature obtained through textbooks, online PubMed, and Google Scholar database searches, author photography, and adapted figures were used.

STUDY SELECTIONS

Studies on the evaluation of ACD and specific skin contact allergens were selected, with a focus on original research articles and clinical reviews.

RESULTS

Major classifications of common contact allergens include the following: (1) fragrances, (2) preservatives, (3) excipients, (4) rubber chemicals, (5) textile dyes, (6) topical medications, and (6) metals and other biomedical device components. The dermatitis distribution can aid in identifying the suspected contact allergen culprit. Certain contact allergens have features that are important to consider in the patch testing (PT) interpretation; these include possible irritant reactions, false-negative reactions or missed detection, and delayed reactions. Fragrances, preservatives, and excipients are culprits in personal products and facial or neck dermatitis. Patch testing with fragrances, preservatives, and patient-supplied products requires careful interpretation. Hand or foot dermatitis may be attributed to rubber chemicals or textile dyes. The management of topical corticosteroid contact allergy is guided on the basis of structural group classifications. Metal sensitization has been associated with dermatitis or biomedical device complications.

CONCLUSION

Each skin contact allergen has unique characteristics with regard to the dermatitis clinical presentation and potential PT nuances. These features are critical to recognize in the evaluation of ACD and PT interpretation and clinical relevance, leading to an accurate diagnosis.

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.

Impact in Contact Dermatitis during and after SARS-CoV2 Pandemic

Purpose of the review

Due to the recent COVID-19 pandemic, several skin conditions have emerged due to the preventive measures adopted by both health care workers and the general population against SARS-CoV-2. Above all, wearing of personal protective equipment, frequent hand-washing and disinfecting of surfaces have resulted in an increased risk of irritant or allergic contact dermatitis. The aim of this review is to investigate contact dermatitis associated with COVID-19 pandemic period.

Recent findings

There is a real evidence of the rising prevalence of irritant and allergic contact dermatitis in response to the COVID-19 pandemic. The most commonly recorded symptoms are dryness, itch and redness of the skin. Nasal bridge, cheeks, forehead and hands represent the mainly affected skin sites.

Summary

Contact dermatitis lesions may appear as a result of various recommendations to prevent transmission of COVID-19. Procedures to alleviate pressure and friction, gentle skin care and adequate moisturizing, have been identified as important preventive strategies for contact dermatitis related to personal protective equipment and personal hygiene measures.

Technologies for Type 1 Diabetes and Contact Dermatitis: Therapeutic Tools and Clinical Outcomes in a Cohort of Pediatric Patients

The increasing use of technological devices for the management of diabetes is related to the prolonged exposure of patients' skin to chemical and mechanical agents and, consequently, to the increased risk of developing dermatological complications. Among these, contact dermatitis is the most insidious skin disorder. Despite the magnitude of the issue, no universally accepted recommendations on the management of this common complication are currently available. Our observational study aimed to describe all the solutions adopted by patients and their caregivers to treat and prevent the appearance of contact dermatitis and to describe the clinical impact of this cutaneous complication. Twenty-one pediatric patients (mean age 12.1 ± 3.7 years) with type 1 diabetes were recruited in the study. The most common treatment used to treat acute skin lesions was the application of topical corticosteroids, sometimes associated with topical antibiotics (9.5%). In order to prevent the further appearance of dermatitis, the most frequently adopted measure was the use of hydrocolloid and/or silicone-based adhesives, followed by the application of protective barrier films. One patient reported benefit from the off-label use of fluticasone propionate nasal spray. However, only 52.4% of the study participants achieved a definitive resolution of the skin issue, and 38.1% of patients were forced to discontinue insulin pump therapy and/or continuous glucose monitoring. No differences were observed in glycated hemoglobin values between the period before and after the onset of contact dermatitis. Our study confirms the severity of this dermatological complication that may hinder the spread of new technologies for the management of diabetes. Finally, our findings highlight the importance of establishing close collaboration both with pediatric allergy specialists to prescribe the most suitable treatment and with manufacturing companies to ensure that adhesives of technological devices are free of harmful well-known sensitizers.

Comparison of chlorhexidine impregnated dressing and standard dressing for the prevention of central-line associated blood stream infection and colonization in critically ill pediatric patients: A randomized controlled trial

BACKGROUND

The aim of this study was to compare chlorhexidine gluconate (CHG)-impregnated dressing and standard dressing with respect to the frequency of central-line-associated bloodstream infection (CLABSI), catheter-related bloodstream infection, primary bloodstream infection, and catheter colonization in critically ill pediatric patients with short-term central venous catheters.

METHODS

Children who were admitted to the pediatric intensive care unit of a tertiary institution between May 2018 and December 2019 and received placement of a short-term central venous catheter were included in this single-center randomized controlled trial. Patients were grouped according to the type of catheter fixation applied.

RESULTS

A total of 307 patients (151 CHG-impregnated dressing, 156 standard dressing), with 307 catheters (amounting to a collective total of 4,993 catheter days), were included in the study. The CHG-impregnated dressing did not significantly decrease the incidence of CLABSI (6.36 vs 7.59 per 1,000 catheter days; hazard ratio (HR): 0.93, P = 0.76), catheter related bloodstream infection (3.82 vs 4.18 per 1,000 catheter days; HR: 0.98; P = 0.98), and primary bloodstream infection (2.54 vs 3.42 catheter days; HR: 0.79; P = 0.67). The CHG-impregnated dressing significantly decreased the incidence of catheter colonization (3.82 vs 7.59 per 1,000 catheter days; HR: 0.40; P = 0.04). In both groups, the most frequent microorganisms isolated in CLABSI or catheter colonization were Gram-positive bacteria (the majority were coagulase-negative staphylococci).

CONCLUSIONS

The use of CHG-impregnated dressing does not decrease CLABSI incidence in critically ill pediatric patients but it significantly reduced catheter colonization. Coagulase-negative staphylococci were the most common microorganisms causing CLABSI or catheter colonization.

Clinical, Endoscopic, and Histologic Benefit With Comprehensive Type IV Hypersensitivity Patch Testing in Adults With Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated disorder of increasing incidence.¹ Although empiric elimination diets are commonly used EoE therapies, adoption of allergy testing to guide elimination diets has been more limited.^2,3 This likely stems from testing that has often focused on immediate type I hypersensitivity (ie, skin-prick or serum-specific IgE testing) rather than comprehensive type IV hypersensitivity patch tests (CPT), which identify delayed-type allergens.⁴ Although atopy patch tests have been less successful for food triggers, CPTs can evaluate the potential role of additives and aeroallergens in EoE.⁵ Our study aimed to determine if avoiding aeroallergens and additives to everyday products based on a CPT would lead to symptomatic and histologic improvement in patients with EoE who had not responded to proton pump inhibitors (PPIs) alone.

Acceptance of semipermeable glove liners compared to cotton glove liners in health care workers with work-related skin diseases: Results of a quasi-randomized trial under real workplace conditions

BACKGROUND

Glove liners (GLs) made of cotton (COT) are worn under impermeable gloves to prevent occlusion effects. Semipermeable GLs made of Sympatex (SYM) might be an alternative.

OBJECTIVES

To evaluate the acceptance of GLs (COT/SYM) in health care workers (HCWs) with work-related skin diseases (WRSDs).

METHODS

One hundred sixty-one HCWs with WRSDs were asked to wear GLs in combination with occlusive gloves for 10 ±2 weeks under workplace conditions. A questionnaire was applied to compare acceptance and usability of the respective glove combinations and previously used protective gloves (PUGs).

RESULTS

A total of 120 data sets were available (SYM: n = 65, 77.4%; COT: n = 55, 71.4%). Both GLs provided a significantly lower sweating sensation, more pleasant climate, comfortable wearing experience, and moist or dry feeling on the skin compared to PUGs. SYM-GLs performed significantly better than COT-GLs regarding mobility of hands, sensitivity, and sense of touch. COT-GLs were significantly better than SYM-GLs in the categories fit, donning and doffing, and material contact.

CONCLUSIONS

Both GLs did not impair work performance, were applicable in various areas of health care activities, and were preferred over PUGs. Our results indicate that SYM-GLs are an alternative to COT-GLs and thus may contribute to current prevention strategies.

In Vitro and Clinical Safety Assessment of the Multiple W/O/W Emulsion Based on the Active Ingredients from Rosmarinus officinalis L., Avena sativa L. and Linum usitatissimum L

The multiple W/O/W emulsion supplemented with the extracts of Rosmarinus officinalis L., Avena sativa L. and Linum usitatissimum L. was prepared in the study, its active compounds were determined by HPLC and its safety was evaluated in vitro by the means of reconstituted human skin model EpiDerm™ for the assessment of its irritation, phototoxicity and early skin inflammation effects and by the 48 h human skin patch test for its skin irritation and allergenic potential. The microbiological challenge test of W/O/W emulsion was performed to ensure its preservation efficiency. The results showed that the W/O/W emulsion loaded with self-preserving plant-based bio-actives had no irritant potential, was not phototoxic and did not provoke skin inflammation or sensitization and thus could be used as a safe base for cosmetic products. Furthermore, our results demonstrate that the safety evaluation of cosmetic ingredients of natural or organic origin could be easily performed using reconstructed human skin model EpiDerm™ similar to the well-defined chemicals used in the cosmetics industry.

Occupational Contact Dermatitis: An Update

Occupation contact dermatitis (CD) is a common inflammatory skin condition impacting every professional industry in the United States. It is associated with significant personal and professional distress, loss of revenue, and decreased productivity. Occupational CD is further subdivided into irritant CD and allergic CD. Frequently, workers may suffer from a combination of both types. Numerous workplace exposures are implicated, but there are several themes across professions, such as CD related to frequent handwashing and wet work. A detailed occupational history, physical examination, and patch testing can help to make the diagnosis. Treatment includes identification of the substance and avoidance, which often is quite challenging.

Delabeling Delayed Drug Hypersensitivity: How Far Can You Safely Go?

Delayed immune-mediated adverse drug reactions (IM-ADRs) are defined as reactions occurring more than 6 hours after dosing. They include heterogeneous clinical phenotypes that are typically T-cell-mediated reactions with distinct mechanisms across a wide spectrum of severity from benign exanthems through to life-threatening cutaneous or organ-specific diseases. For mild reactions such as benign exanthem, considerations for delabeling are similar to immediate reactions and may include a graded or single-dose drug challenge with or without preceding skin or patch testing. Evaluation of challenging cases such as the patient who is on multiple drugs at the time a severe delayed IM-ADR occurs should prioritize clinical ascertainment of the most likely phenotype and implicated drug(s). Although not widely available and validated, procedures such as patch testing, delayed intradermal skin testing, and laboratory-based functional drug assays or genetic (human leukocyte antigen) testing may provide valuable information to further help risk stratify patients and identify the likely implicated and/or cross-reactive drug(s). The decision to use a drug challenge as a diagnostic or delabeling tool in a patient with a severe delayed IM-ADR should weigh the risk-benefit ratio, balancing the severity and priority for the treatment of the underlying, and the availability of alternative efficacious and safe treatments.

Contact Dermatitis in Children

Contact dermatitis (CD) is commonly encountered in the pediatric population. Allergic and irritant are the two forms of CD and both cause significant clinical problems in children, but they are often underrecognized. The skin lesions in CD may be polymorphic and closely mimic other common pediatric skin diseases. The diagnosis usually requires patch testing after obtaining a detailed history and performing a physical examination. Metals, fragrances, and certain preservatives are the most common causative agents in children. This article discusses the pathophysiology, diagnosis, and management of this common skin condition in the pediatric population. [Pediatr Ann. 2021(5):e198-e205.].

What Is New in Occupational Allergic Contact Dermatitis in the Year of the COVID Pandemic?

PURPOSE OF REVIEW

This article aims to summarize some recent trends in occupational allergic contact dermatitis (ACD), including dermatitis related to pandemic-level personal protective equipment in healthcare workers, hazards patients may experience when working from home, and occupational perspectives on the recent American Contact Dermatitis Society (ACDS) allergens of the year and ACDS Core Allergen Series updates.

RECENT FINDINGS

Recent ACDS Allergens of the Year may be particularly relevant to healthcare workers, including isobornyl acrylate, which is present in glucose sensors and propylene glycol present in hand cleansers and disinfectants. Lavender, limonene, and linalool, all of which are new additions to the ACDS Core Allergen Series, have been reported as causes for occupational ACD in massage therapists and aromatherapists. Isothiazolinone allergy continues to rise in both consumer and occupational settings. Finally, the COVID-19 pandemic has resulted in a wave of occupational ACD in healthcare workers to personal protective equipment, and revealed new potential allergens for individuals working from home. Occupational allergic contact dermatitis continues to exert a significant occupational disease burden. Remaining aware of the current trends in allergens may allow for earlier recognition, diagnosis, and treatment, subsequently helping our patients to work in healthier and safer environments.

Hand eczema in children referred for patch testing: North American Contact Dermatitis Group Data, 2000-2016

BACKGROUND

Little is known about the aetiologies and relevant allergens in paediatric patients with hand eczema (HE).

OBJECTIVES

To characterize the aetiologies and determine the proportion of positive and currently relevant allergens in children/adolescents (age < 18 years) with HE referred for patch testing.

METHODS

A retrospective analysis (2000-2016) of North American Contact Dermatitis Group data was performed.

RESULTS

Of 1634 paediatric patients, 237 (14·5%) had involvement of the hands. Final physician diagnoses included allergic contact dermatitis (49·4%), atopic dermatitis (37·1%) and irritant contact dermatitis (16·9%). In multivariable logistic regression models, employment was the only association with increased odds of any HE or primary HE. Children with HE vs. those without HE had similar proportions of positive patch tests (56·1% vs. 61·7%; χ² -test, P = 0·11). The five most common currently relevant allergens were nickel, methylisothiazolinone, propylene glycol, decyl glucoside and lanolin. In multivariable logistic regression models of the top 20 relevant allergens, HE was associated with significantly higher odds of currently relevant reactions to lanolin, quaternium-15, Compositae mix, thiuram mix, 2-mercaptobenzathiazole and colophony. The allergens with the highest mean significance-prevalence index number were methylisothiazolinone, carba mix, thiuram mix, nickel and methylchloroisothiazolinone/methylisothiazolinone.

CONCLUSIONS

Children with HE who were referred for patch testing had a high proportion of positive patch tests, which was similar to the proportion found in children without HE. Children with HE had a distinct and fairly narrow profile of currently relevant allergens.

Facial and neck erythema associated with dupilumab treatment: A systematic review

BACKGROUND

Neither dupilumab-associated facial erythema nor neck erythema was reported in phase 3 clinical trials for the treatment of atopic dermatitis, but there have been a number of reports of patients developing this adverse event in clinical practice.

OBJECTIVE

To outline all cases of reported dupilumab-associated facial or neck erythema to better characterize this adverse event, and identify potential etiologies and management strategies.

METHODS

A search was conducted on EMBASE and PubMed databases. Two independent reviewers identified relevant studies for inclusion and performed data extraction.

RESULTS

A total of 101 patients from 16 studies were reported to have dupilumab-associated facial or neck erythema. A total of 52 of 101 patients (52%) had baseline atopic dermatitis facial or neck involvement and 45 of 101 (45%) reported different cutaneous symptoms from preexisting atopic dermatitis, possibly suggesting a different etiology. Suggested etiologies included rosacea, allergic contact dermatitis, and head and neck dermatitis. Most commonly used treatments included topical corticosteroids, topical calcineurin inhibitors, and antifungal agents. In the 57 patients with data on the course of the adverse events, improvement was observed in 29, clearance in 4, no response in 16, and worsening in 8. A total of 11 of 101 patients (11%) discontinued dupilumab owing to this adverse event.

LIMITATIONS

Limited diagnostic testing, nonstandardized data collection and reporting across studies, and reliance on retrospective case reports and case series.

CONCLUSION

Some patients receiving dupilumab develop facial or neck erythema that differs from their usual atopic dermatitis symptoms. Prompt identification and empiric treatment may minimize distress and potential discontinuation of dupilumab owing to this adverse event.

The erythema Q-score, an imaging biomarker for redness in skin inflammation

Physician rating of cutaneous erythema is central to clinical dermatological assessment as well as quantification of outcome measures in clinical trials in a number of dermatologic conditions. However, issues with inter‐rater reliability and variability in the setting of higher Fitzpatrick skin types make visual erythema assessment unreliable. We developed and validated a computer‐assisted image‐processing algorithm (EQscore) to reliably quantify erythema (across a range of skin types) in the dermatology clinical setting.

Our image processing algorithm evaluated erythema based upon green light suppression differentials between affected and unaffected skin. A group of four dermatologists used a 4‐point Likert scale as a human evaluation of similar erythematous patch tests. The algorithm and dermatologist scores were compared across 164 positive patch test reactions. The intra‐class correlation coefficient of groups and the correlation coefficient between groups were calculated. The EQscore was validated on and independent image set of psoriasis, minimal erythema dose testing and steroid‐induced blanching images. The reliability of the erythema quantification method produced an intra‐class correlation coefficient of 0.84 for the algorithm and 0.67 for dermatologists. The correlation coefficient between groups was 0.85. The EQscore demonstrated high agreement with clinical scoring and superior reliability compared with clinical scoring, avoiding the pitfalls of erythema underrating in the setting of pigmentation. The EQscore is easily accessible (http://lab.rockefeller.edu/krueger/EQscore), user‐friendly, and may allow dermatologists to more readily and accurately rate the severity of dermatological conditions and the response to therapeutic treatments.

Hand dermatitis in adults referred for patch testing: Analysis of North American Contact Dermatitis Group Data, 2000 to 2016

BACKGROUND

Hand eczema (HE) is a heterogeneous and burdensome disorder.

OBJECTIVE

To characterize the clinical characteristics, etiologies and allergen relevance in adults with HE referred for patch testing.

METHODS

Retrospective analysis (2000-2016) of North American Contact Dermatitis Group data (n = 37,113).

RESULTS

Overall, 10,034 patients had HE, with differences of overlap between allergic contact, irritant contact, and atopic dermatitis. Allergic contact HE fluctuated, whereas atopic HE steadily increased, and irritant HE decreased over time. HE was associated with higher proportions of positive patch tests (67.5% vs 63.8%; χ², P < .0001). The five most common clinically relevant allergens were methylisothiazolinone, nickel, formaldehyde, quaternium-15, and fragrance mix I. HE was associated with significantly higher odds of positive patch test reactions and clinical relevance in 13 and 16 of the 25 most common allergens, respectively, including preservatives, metals, topical medications, and rubber accelerators.

LIMITATIONS

No data on HE phenotype.

CONCLUSION

HE in adults was associated with higher proportions of positive patch tests, with a heterogeneous profile of allergens. Patch testing remains an important tool in the evaluation of patients with HE.

Efficacy of oral supplementation of whey protein in patients with contact dermatitis: A pilot randomized double-blind placebo-controlled clinical trial

Whey protein is a popular dietary product that has numerous health benefits such as immune modulation. In this study, we assessed efficacy of whey protein in management of patients with contact dermatitis (CD) through a double blind, randomized controlled clinical trial in Emam Reza clinic, Shiraz, Iran. Twenty-five patients in each group were randomly assigned to receive whey protein or placebo powder, 30 g in 200 mL warm water at fasting time for 4 weeks. Outcome measures were Dermatology Life Quality Index (DLQI) questionnaire and the Eczema Area and Severity Index (EASI) score. Furthermore, subjective total improvement (assessed by visual analogue scale) was set as the other primary outcome measure. A significant decrease was observed in the scores of EASI, DLQI, and subjective total improvement in the drug group after the intervention compared with the baseline. However, no changes were seen in the placebo group. Moreover, there was a significant reduction in the scores of EASI (P = .002) and subjective total improvement scores (P = .039) over the study period in the drug group compared with the placebo group. According to the results of this study, it seems that oral supplementation of whey protein could improve the symptoms of CD compared with placebo.

Efficacy of chlorhexidine patches on central line-associated bloodstream infections in children

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) are important hospital-acquired infections. Chlorhexidine-impregnated dressings (also known as chlorhexidine patches, CHG patches) are reported to decrease CLABSIs in adults. This study aims to determine the efficacy of CHG patches in reducing CLABSIs in children.

METHODS

An open-label randomized controlled trial was conducted in children aged 2 months to 18 years, requiring a short-term catheter. Patients were randomized into two groups, allocated to receive CHG patches or standard transparent dressings. Care of the catheter was in accordance with Asia Pacific Society of Infection Control (APSIC) recommendations. Central-line-associated bloodstream infections were defined using National Healthcare Safety Network surveillance criteria.

RESULTS

From April 2017 to April 2018, 192 children were enrolled. There were 108 CHG patch catheters and 101 standard dressing catheters, contributing to 3,113 catheter days. The median duration of catheter dwelling was 13 days, with an interquartile range (IQR) of 8-20 days. Half were placed at the jugular vein and 22% at the femoral vein. There were 23 CLABSI events. Incidence rates for CHG patches and standard dressings were 7.98 (95% confidence interval (CI), 4.25-13.65) and 6.74 (95% CI, 3.23-12.39) per 1,000 catheter days, respectively (incidence rate ratio 1.18; 95% CI, 0.52-2.70). The CLABSI pathogens were 15 Gram-negative bacteria, six Gram-positive bacteria, and two Candida organisms. Catheter colonization of CHG patches and standard dressings were 2.02 (95% CI, 0.42-5.91) and 3.07 (95% CI, 1.00-7.16) per 1,000 catheter days, respectively. Only local adverse effects occurred in 6.8% of the participants.

CONCLUSIONS

In our setting, there was no difference in CLABSI rates when the chlorhexidine patch dressings were compared with the standard transparent dressings. Strengthening of CLABSI prevention bundles is mandatory.

Contact dermatitis: Clinical practice findings from a single tertiary referral hospital, a 4-Year retrospective study

BACKGROUND

It is estimated that 20% of the general population is sensitized to some kind of contact allergen. Contact dermatitis is one of the major occupational diseases worldwide. This disease has a higher prevalence in the female gender and is more frequently observed in the third or fourth decade of life. The main objective of this study was to describe the main sociodemographic and clinical characteristics of patients with contact dermatitis treated in the Allergy Unit of the San Juan De Dios Hospital - Caja Costarricense de Seguro Social.

METHODS

Clinical records of contact dermatitis outpatients from a single hospital were analyzed, in a 4-year retrospective observational study.

RESULTS

At the time of the patch testing, patients showed a mean age of 42.2 years. Disease frequency was higher in the female population (female/male ratio of 4.2:1) and in patients mostly dedicated to household workchores. Most patients presented several years of disease history, and the hands were the highest affected body part. Patch testing revealed that nickel sulfate, Cl+Me-Isothiazolinone (Kathon CG), and thimerosal were allergens regularly associated with contact dermatitis in the analyzed population.

CONCLUSIONS

To a great extent, sociodemographic and clinical characteristics identified in these patients resemble what is reported in other regions, including the Americas and worldwide. It is worth highlighting a high female proportion rate probably related to cultural aspects, a smaller percentage of irritant contact dermatitis that may be associated to institutional patient management, and a slight difference in the most common allergens when compared to other published studies.

Using health insurance administrative data to explore patch testing utilization in Ontario, Canada-An untapped resource

BACKGROUND

Patch testing is the key diagnostic test for diagnosing allergic contact dermatitis, but there is limited information on the use of patch testing at the population level.

OBJECTIVES

To utilize Ontario Health Insurance Plan (OHIP) data to analyse trends in the rate of patch testing in Ontario.

METHODS

Patch testing billing data submitted to the OHIP between 1992 and 2014 were analysed. Two patch test billing codes were investigated: one for work-related testing (G198), and one for non-work-related testing (G206). Rates of patch testing overall were calculated, and trends over time were described.

RESULTS

There were 51 576 patch test billings: 48 416 non-work-related and 3160 work-related. The annual rate of non-work-related patch testing (G206) ranged from 11.9 per 100 000 people to 25.9 per 100 000 people, increasing over time. The rate of work-related patch testing (G198) ranged from 0.17 to 2.32 per 1 000 000 people, and was relatively stable. The overall distribution of billing by specialty was 70% dermatology, 19% other medical subspecialties, and 10% paediatrics and family medicine.

CONCLUSIONS

Administrative health data can contribute to a more complete understanding of patch test utilization at the population level and, over time, can be used to track patch testing practices.

Asteraceae species as potential environmental factors of allergy

The statistics from Europe and the USA have proven a high risk for skin diseases associated with plant contact. Therefore, plant-induced dermatitis is of increasing attention in dermatology. The focus of this paper was to present the current knowledge on aspects of contact allergy related to Asteraceae (Compositae) species. The Asteraceae family is one of the largest in the world with members across all continents. The PubMed/Medline databases have been searched. The Asteraceae representatives consist of diverse secondary metabolites, which exhibit various advantageous effects in humans. In particular, sesquiterpene lactones (SLs) may cause sensitization resulting in skin irritation and inflammation. In this study, we tried to reveal the allergenic potential of several Asteraceae species. The Asteraceae-related allergy symptoms involve eczema, hay fever, asthma, or even anaphylaxis. Furthermore, the evidence of severe cross-reactivity with food and pollen allergens (PFS) in patients sensitive to Asteraceae allergens have been announced. Further identification and characterization of secondary metabolites and possible allergens in Asteraceae are necessary for the better understanding of Asteraceae-related immune response. The Asteraceae allergy screening panel (the SL mix and the Compositae mix of five plant species) is a promising tool to improve allergy diagnostics and therapy.

Diagnostic utility of skin autofluorescence when patch test results are doubtful

BACKGROUND

The standard diagnostic test for allergic contact dermatitis is the patch test, which can also be used to identify irritant contact dermatitis. Doubtful reactions (?+) can be often clinically relevant to individuals and can require additional tests.

OBJECTIVES

The purpose of this study was to examine whether autofluorescence (AF) measurements in patients with doubtful reactions are helpful in diagnosing contact dermatitis.

METHODS

Patients with a history of contact dermatitis were patch tested on the upper back for 48-hours of occlusion using aqueous solutions of 5% sodium lauryl sulfate. Reaction intensity was scored, and AF was measured on reactive lesions and non-lesions. Three dermatologists classified the results as positive or negative using the fluorescence photographs of patients with a doubtful reaction.

RESULTS

Among doubtful reactions, the R/G% values were significantly higher in the AF- based positive group than in the negative group (P = .0086). On the other hand, the heterogeneity values of R, G, and B (HR, HG, HB) were significantly lower in the AF-based positive group (P = .0026, .0046, .0004 respectively).

CONCLUSIONS

Measuring AF along with the clinical readings can help confirm doubtful patch test reactions.

Hand eczema as a risk factor for food allergy among occupational kitchen workers

BACKGROUND

An increasing number of studies in children is highlighting the importance of transdermal routes of exposure to food allergens through damaged skin in the pathogenesis of food allergies. However, data on this in adults are limited. A few case-series studies has documented development of food allergy among kitchen workers with hand eczema after direct contact exposure to foods.

METHODS

To explore the significance of hand eczema as a risk factor for food allergies in adults at the epidemiological level, we performed a cross-sectional web-based questionnaire survey on kitchen workers whose exposures were classed as occupational (cooks and food handlers, n = 1592) or non-occupational (housewives, n = 1915). Logistic regression was used to explore the association between the presence/severity of hand eczema and the risk of food allergy after adjustment for potential confounders.

RESULTS

Current hand eczema and current diagnosed food allergy were more common among occupational kitchen workers (OKW) than among non-occupational kitchen workers (NOKW) (32.3%-vs-29.9% and 9.9%-vs-3.8%, respectively). Current hand eczema was significantly associated with increased risk of current diagnosed food allergy in OKW (adjusted odds ratio 2.4, 95% CI 1.6-3.7). Those with more severe hand eczema were more likely to suffer from allergic symptoms for foods, and diagnosed food allergy.

CONCLUSIONS

This study illustrates a significant public health problem in the adult population, documenting a major impact of hand eczema on the ongoing adult food allergy epidemic.

Contact dermatitis and patch testing for the allergist

OBJECTIVE

To review of contact dermatitis (CD) and its key allergens and provide updates and recommendations for the practicing allergist.

DATA SOURCES

Through the use of various scientific search engines (eg, PubMed and MEDLINE), we reviewed literature on CD, patch tests (PTs), key allergens, occupational dermatitis, and treatment.

STUDY SELECTIONS

Studies on CD, important allergens, and PTs were considered.

RESULTS

Contact-induced dermatitis may be due to allergic CD, irritant CD, systemic CD, contact urticaria, and protein CD. Key allergens include metals (nickel, gold), topical medicaments (topical corticosteroids), and cosmetics and personal care products (fragrances and preservatives such as methyl- and methylchloro-isothiazolinone). Present relevance of a positive PT result is the combination of definite, probable, and possible relevance and should be correlated with the patient's history and physical examination. Treatment of allergic CD includes identification of relevant allergens, patient education, avoidance, and provision of alternative products the patient can use.

CONCLUSION

CD is a common inflammatory skin disease and should be suspected in patients presenting with acute, subacute, or chronic dermatitis. The gold standard for diagnosing allergic CD is a PT. This article provides practical recommendations for the diagnosis and management of CD commonly seen by the allergist in their practice.