Nickel allergy and its relationship with local nickel pollution, ear piercing, and atopic dermatitis: a population-based study from Norway

Cross-sectional observational study exploring clinical risk of titanium allergy caused by dental implants

PURPOSE

Studies have reported cases of metal allergy caused by titanium-containing materials. We wished to clarify the relationship between titanium allergy and dental implants by describing patients who suffered allergic symptoms after they had received such implants.

METHODS

A total of 270 patients who visited a Dental Metal Allergy Clinic at Tokushima University Hospital from April 2010 to March 2014 were the study cohort. Patch testing with 28 types of metal allergens (including four titanium allergens) was undertaken for patients.

RESULTS

A total of 217 patients (80.4 %) exhibited allergy-positive reactions to at least one type of metal allergen. Mercury, palladium, chromium and nickel exhibited a higher prevalence of allergy-positive reactions than other metals. Sixteen patients visited our clinic suffering allergic symptoms after receiving dental implants. Eleven of those patients exhibited allergy-positive reactions for any of the metal allergens, and 4 of these patients had allergy-positive reactions against titanium allergens. The total number of allergy-positive reactions for titanium allergens among all 270 patients was 17 (6.3 %). No patient exhibited a positive reaction only for the titanium allergen.

CONCLUSIONS

The prevalence of allergy-positive reactions for titanium allergens was lower than for other metal allergens. We suggest examination of pre-implant patients who have a history of hypersensitivity reactions to metals.

Prevalence of contact allergy to metals in the European general population with a focus on nickel and piercings: The EDEN Fragrance Study

Background

Studies on sensitization to metals in the general population are scarce.

Objectives

To determine the prevalence of sensitization to metals in the general population, and factors associated with nickel sensitization.

Methods

In 5 European countries (The Netherlands, Germany, Italy, Portugal and Sweden), a random sample (N = 3119) from the general population (aged 18‐74 years) was patch tested and interviewed by use of a questionnaire on exposure to metals, piercing, and jewellery.

Results

Overall, the age‐standardized prevalences of sensitization to nickel, cobalt and chromium were, respectively, 14.5%, 2.1%, and 0.8%. The highest prevalence of nickel sensitization was seen in Portugal (18.5%) and the lowest (8.3%) in Sweden. The prevalence of cobalt sensitization varied between 3.8% (The Netherlands) and 0.9% (Italy), and the prevalence of chromium sensitization varied between 1.3% (Portugal) and 0.2% (Sweden). Significant associations were observed between nickel allergy and female sex (odds ratio [OR] 5.19; 95% confidence interval [95%CI]: 3.99‐6.74), past piercing use (OR 3.86; 95%CI: 2.85‐5.24), and currently having ≥3 piercings (OR 5.58; 95%CI: 4.02‐7.76).

Conclusions

The prevalence of sensitization to metals in the European general population was high, mostly because of nickel. The lowest prevalence of contact allergy to nickel and chromium observed in Sweden supports the effectiveness of long‐standing regulation.

Delayed-type hypersensitivity to metals in connective tissue diseases and fibromyalgia

Rheumatic diseases include a group of autoimmune disorders with environmental and genetic etiology that are characterized as a subgroup of connective tissue diseases (CTD). Rheumatoid arthritis (RA) often involves the small joints of the hands in a symmetrical fashion that can lead to loss of joint function, and RA, as well as Sjögren's syndrome (SS) and other rheumatic diseases, are often accompanied by sensitivity to metals. Numerous investigations on metal sensitivity were evaluated in this review. A detailed metal exposure history was collected by different evaluation of studies. In all subjects, the main source of metal exposure was nickel, mercury, gold, palladium, titanium, and chromium. All of SLE (systemic lupus erythematosus), RA and SS patients appeared to have an increased frequency of metal delayed-type hypersensitivity (DTH) (Type IV allergy). As dental restorative materials release minor amounts of their metals (including mercury, gold, and nickel), many adults are commonly exposed to these metal ions by vapor or corrosion into saliva. Metal-related DTH in these patients will induce an inflammatory response. Such inflammations are important factors in CTD progress. It is hypothesized that metal-specific T cell reactivity can act as an etiological agent in the propagation and chronification of rheumatic inflammation. The key responses of metal delayed-type hypersensitivity in autoimmunity are precipitating as an appealing challenge for further investigations.

Nickel sensitivity in patients with gastroesophageal reflux disease

OBJECTIVE

Various foods play important role in the pathogenesis of gastroesophageal reflux disease (GERD). These foods are shown to increase gastroesophageal reflux symptoms via various mechanisms and majority of these foods also contain nickel. The purpose of this study is to evaluate the relationship between Nickel sensitivity and GERD.

MATERIAL AND METHODS

Fifty-four patients diagnosed with GERD and 50 healthy volunteers who were admitted to our gastroenterology outpatient clinic were took part in the study. European standard patch test series, nickel-containing test units and corticosteroids were applied to the patient body; upper back. Evaluation was performed according to the scheme of the International Contact Dermatitis Research Group (ICDRG). The positive and negative reactions were recorded at the hours of 48, 72 and 96. Following the test implementations, 7 days later, the tests were reevaluated for late reactions. Statistics package for Social Sciences (SPSS) 17 package program was used for statistical evaluation and results of tests were compared between groups with the Chi-squared test. p < 0.05 was considered statistically significant.

RESULTS

Individuals in both groups were statistically similar in terms of age and gender. Nickel sensitivity was found to be positive in 48.2 and %22 of the GERD patients and control group, respectively. Difference between groups was statistically significant (p = 0.008).

CONCLUSIONS

Nickel sensitivity was significantly higher in GERD patients compared to the control group. In addition to imbalance between defensive and aggressive forces of the esophagus, there seems to be an association between nickel sensitivity and GERD.

Derivation of an oral toxicity reference value for nickel

Nickel (Ni) is in the earth's crust and can be found in environmental compartments such as water, soil, and air, as well as food. This paper presents an assessment of the oral nickel toxicity data in support of non-cancer health-based oral exposure limits or toxicity reference values (TRVs). This paper derives TRVs for three populations of interest: adults, toddlers, and people who have been dermally sensitized to nickel. The adult/lifetime TRV of 20 μg Ni/kg-day is based on post-implantation loss/perinatal mortality in a 2-generation reproductive study in rats. Several recent assessments by regulatory agencies have used the same study and endpoint, but the dose-response modeling conducted here was more appropriate for the study design. Toxicokinetic data from rats and humans indicate that the applied uncertainty factors are very conservative. Because the endpoint relates to fetal exposure and is not relevant to toddlers, a toddler TRV was derived based on decreased body weight in young rats; this TRV was also 20 μg Ni/kg-day. A separate TRV of 4 μg Ni/kg in addition to Ni in food was derived for protection of nickel-sensitized populations from flare-up of dermatitis, based on studies of single exposures in humans under conditions that maximize oral absorption.

Delayed-Type Hypersensitivity to Metals of Environmental Burden in Patients with Takotsubo Syndrome - Is There a Clinical Relevance?

Objective

Takotsubo syndrome (TS) is a heart condition characterised by a sudden transient left ventricular dysfunction; its pathophysiology is probably associated with elevated levels of catecholamines but the exact mechanism is not known as yet. Literature and clinical experience suggest that TS affects persons with various comorbidities. This pilot work aims to evaluate the frequency of comorbidities with potential pathological immune reactivity, and to evaluate the potential association between TS and hypersensitivity to metals assessed by LTT-MELISA®.

Methodology, Results

A total of 24 patients (23 women, 1 man) with a history of TS attack and 27 healthy controls were evaluated. Hypersensitivity was evaluated by a lymphocyte transformation test (LTT-MELISA®); a questionnaire of environmental burden was used to select evaluated metals. A total of 19 patients (79%) had at least one condition that might potentially be associated with pathological immune reactivity (autoimmune thyroid disease, drug allergy, bronchial asthma, cancer, contact dermatitis, rheumatoid arthritis). Hypersensitivity to metals was identified significantly more frequently in TS patients than in healthy controls (positive reaction to at least one metal was identified in 95.8% of TS patients and in 59.3% of controls; p = 0.003); the difference was statistically significant for mercury (45.8% and 14.8%, respectively; p = 0.029).

Conclusion

Our work shows that conditions with pathological immune reactivity occur frequently in TS patients, and our data suggest a possible association between TS and hypersensitivity to metals (mercury in particular) evaluated by LTT-MELISA®. We also suggest that apart from the triggering stress factor, potential existence of other serious conditions should be considered when taking medical history of TS patients.

Increased frequency of delayed type hypersensitivity to metals in patients with connective tissue disease

BACKGROUND

Connective tissue disease (CTD) is a group of inflammatory disorders of unknown aetiology. Patients with CTD often report hypersensitivity to nickel. We examined the frequency of delayed type hypersensitivity (DTH) (Type IV allergy) to metals in patients with CTD.

METHODS

Thirty-eight patients; 9 with systemic lupus erythematosus (SLE), 16 with rheumatoid arthritis (RA), and 13 with Sjögren's syndrome (SS) and a control group of 43 healthy age- and sex-matched subjects were included in the study. A detailed metal exposure history was collected by questionnaire. Metal hypersensitivity was evaluated using the optimised lymphocyte transformation test LTT-MELISA(®) (Memory Lymphocyte Immuno Stimulation Assay).

RESULTS

In all subjects, the main source of metal exposure was dental metal restorations. The majority of patients (87%) had a positive lymphocyte reaction to at least one metal and 63% reacted to two or more metals tested. Within the control group, 43% of healthy subjects reacted to one metal and only 18% reacted to two or more metals. The increased metal reactivity in the patient group compared with the control group was statistically significant (P<0.0001). The most frequent allergens were nickel, mercury, gold and palladium.

CONCLUSIONS

Patients with SLE, RA and SS have an increased frequency of metal DTH. Metals such as nickel, mercury and gold are present in dental restorative materials, and many adults are therefore continually exposed to metal ions through corrosion of dental alloys. Metal-related DTH will cause inflammation. Since inflammation is a key process in CTDs, it is possible that metal-specific T cell reactivity is an etiological factor in their development. The role of metal-specific lymphocytes in autoimmunity remains an exciting challenge for future studies.

Allergy and orthodontics

The aim of this paper is to review the current literature on allergy in orthodontics and to identify the predisposing factors and the implications of the allergic reaction in the management of patients during orthodontic treatment. A computerized literature search was conducted in PubMed for articles published on allergy in relation to orthodontics. The MeSH term used was allergy and orthodontics. Allergic response to alloys in orthodontics, particularly nickel, has been extensively studied and several case reports of nickel-induced contact dermatitis have been documented. Current evidence suggests that the most common allergic reaction reported in orthodontics is related to nickel in orthodontic appliances and allergic response is more common in women due to a previous sensitizing exposure from nickel in jewellery. Studies have implicated allergy in the etiology of hypo-dontia. It has also been considered as a high-risk factor for development of extensive root resorption during the course of orthodontic treatment. This review discusses the relationship and implications of allergy in orthodontics.

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.

Prevalence of nickel sensitization and urinary nickel content of children are increased by nickel in ambient air

In a cross-sectional study performed in 2000, an unexpected positive association between nickel (Ni) in ambient air, urinary Ni content and the prevalence of Ni sensitization in a subgroup of 6-yr-old children living near a steel mill was observed. Between 2005 and 2006, in a different and larger study population, we examined if Ni from ambient air or urinary Ni concentration was related to Ni sensitization in children living next to Ni-emitting steel mills. We studied 749 school beginners living in four Ni-polluted industrial areas of North Rhine-Westphalia, Germany. We assessed Ni in ambient air, Ni in urine from children and mothers, and Ni in tap water, conducted patch tests in children (including the NiSO(4)-dilution test) and collected questionnaire data. Statistics were done by linear and logistic regression analyses, adjusted for covariates. At increased Ni concentration in ambient air (unit of increase: 10 ng/m(3)), urinary Ni concentrations rose in both mothers (9.1%; 95% CI: 6.8-11.4%) and children (2.4%; 95% CI: 0.4-4.4%). The prevalence of Ni sensitization in children was associated with increased Ni from ambient air (unit of increase: 18 ng/m(3); odds ratio 1.28; 95% CI: 1.25-1.32) and urinary Ni concentration (unit of increase: 7.1 μg/L; odds ratio 2.4; 95% CI: 1.20-4.48). Ni in ambient air of areas with Ni-emitting factories contributes to internal Ni exposure in residents via inhalation and, furthermore, is a risk factor for the development of Ni sensitization in children.

The association between metal allergy, total hip arthroplasty, and revision

BACKGROUND AND PURPOSE

It has been speculated that the prevalence of metal allergy may be higher in patients with implant failure. We compared the prevalence and cause of revisions following total hip arthroplasty (THA) in dermatitis patients suspected to have contact allergy and in patients in general with THA. Furthermore, we compared the prevalence of metal allergy in dermatitis patients with and without THA.

MATERIALS AND METHODS

The Danish Hip Arthroplasty Registry (DHAR) contained detailed information on 90,697 operations. The Gentofte patch-test database contained test results for patients suspected of having allergic contact dermatitis (n = 18,794). Cases (n = 356) were defined as patch-tested dermatitis patients who also had primary THA performed. Two age- and sex-matched controls (n = 712) from the patch-test database were sought for each case.

RESULTS

The prevalence of revision was similar in cases (12%) and in patients from the DHAR (13%). The prevalence of metal allergy was similar in cases and controls. However, the prevalence of metal allergy was lower in cases who were patch-tested after operation (6%) than in those who were patch-tested before operation (16%) (OR = 2.9; 95% CI = 1-8).

INTERPRETATION

We found that the risk of surgical revision was not increased in patients with metal allergies and that the risk of metal allergy was not increased in cases who were operated, in comparison to controls. Despite some important study limitations, our observations add to the evidence that the risk of complications in metal allergic patients seems limited.

The epidemiology of contact allergy in the general population--prevalence and main findings

A substantial number of studies have investigated the prevalence of contact allergy in the general population and in unselected subgroups of the general population. The aim of this review was to determine a median prevalence and summarize the main findings from studies on contact allergy in the general population. Published research mainly originates from North America and Western Europe. The median prevalence of contact allergy to at least 1 allergen was 21.2% (range 12.5-40.6%), and the weighted average prevalence was 19.5%, based on data collected on all age groups and all countries between 1966 and 2007. The most prevalent contact allergens were nickel, thimerosal, and fragrance mix. The median nickel allergy prevalence was 8.6% (range 0.7-27.8%) and demonstrates that nickel was an important cause of contact allergy in the general population and that it was widespread in both men and women. Numerous studies demonstrated that pierced ears were a significant risk factor for nickel allergy. Nickel was a risk factor for hand eczema in women. Finally, heavy smoking was associated with contact allergy, mostly in women. Population-based epidemiological studies are considered a prerequisite in the surveillance of national and international contact allergy epidemics.

Allergic contact sensitization in the general adult population: a population-based study from Northern Norway

Few studies have so far addressed the prevalence and risk factors for contact sensitization in the general adult population; however, many such studies have been conducted in hospitals. We present the prevalence of contact sensitization in a general adult population and its relationship to potential risk factors like smoking, ear piercing and atopic diseases. 1236 adults (44.2% men and 55.8% women) were randomly selected from a cross-section of the population in Sør-Varanger municipality, Norway, and patch tested with TRUE Test (Pharmacia, Hillerød, Denmark). Contact sensitivity to at least 1 out of 24 allergens was found in 35.4% of the women and in 14.8% of the men. The most common allergens were nickel (17.6%), cobalt (2.8%), thiomersal (1.9%), fragrance mix (1.8%) and colophony (1.2%). All other allergens were observed in 1.0% or less. In women, ear piercing was an important risk factor for nickel sensitization. No such significant correlation was seen in men [in women relative risk (RR) = 3.30, 95% confidence interval (CI) = 2.01-5.43, and in men RR = 1.82, 95% CI = 0.66-5.00], and contact sensitivity was associated with atopic dermatitis (AD) [adjusted odds ratio (OR) = 1.58, 95% CI = 1.04-2.40] and smoking (adjusted OR = 1.42, 95% CI = 1.01-1.99) in women but not in men. The prevalence of contact sensitivity was common in this general population, especially in women. Smoking and AD might be a risk factor for contact sensitization.

Serum levels of iron in Sør-Varanger, Northern Norway--an iron mining municipality

OBJECTIVES

The purpose of this study was to investigate iron status in a population with a high proportion of miners in the northernmost part of Norway.

STUDY DESIGN

Cross-sectional, population-based study performed in order to investigate possible health effects of pollution in the population living on both sides of the Norwegian-Russian border.

METHODS

All individuals living in the community of Sør-Varanger were invited for screening in 1994. In 2000, blood samples from 2949 participants (response rate 66.8 %), age range 30-69 years, were defrosted. S-ferritin and transferrin saturation were analysed in samples from 1548 women and 1401 men. About 30 % (n = 893) were employed in the iron mining industry, 476 of whom were miners and 417 had other tasks in the company. Type and duration of employment and time since last day of work at the company were used as indicators of exposure.

RESULTS

Both s-ferritin levels and transferrin saturation were higher in men than in women. S-ferritin increased with increasing age in women, while the opposite was true for men. Iron deficiency occurred with higher frequencies in women (16 %) than in men (4 %). Iron overload was uncommon in both sexes. Adjustment for smoking and self-reported pulmonary diseases did not show any effect on iron levels. Miners had non-significant higher mean s-ferritin and transferrin saturation than non-miners. Neither duration, nor time since employment in the mine, had any impact on iron status.

CONCLUSIONS

Our analyses did not show any associations between being a miner in the iron mining industry and serum iron levels compared to the general population.

Adverse consequences of tattoos and body piercings

Body piercings and tattoos are becoming more common in the adolescent population today. Despite their movement into mainstream society, literature to aid in counseling of teens about these issues is scant. The practitioner dealing with this population of patients must be armed with the information necessary that will help adolescents make informed decisions about tattoos and piercings.

Atopy in Norwegian and Russian adults: a population-based study from the common border area

BACKGROUND

Several studies have concluded that atopy is more common in Western than in Eastern Europe. We aimed to study whether a similar difference exists between Norwegian and Russian adults living in geographically adjacent areas.

METHODS

A cross-sectional population-based study was performed in Sør- Varanger municipality (Norway) and in the cities of Nikel and Zapolyarny (Russia). The Russian cities are heavily polluted by sulfur dioxide from local nickel industry. In addition to questionnaire information, results on IgE sensitization (S-Phadiatop, Pharmacia & Upjohn, Uppsala, Sweden) were obtained from 3134 Norwegian and 709 Russian participants.

RESULTS

A positive Phadiatop was found in 20.7% of the Norwegians (men 21.9%, women 19.7%) and in 27.5% of the Russians (men 35.7%, women 23.0%); the sex- and age-adjusted relative risk of testing positive in Russia being 1.49 (95% CI 1.23-1.81). The Norwegian participants reported more atopic dermatitis and hay fever, although this difference was statistically significant only for atopic dermatitis in women.

CONCLUSION

IgE sensitization was more common in Russia than in Norway, unlike findings from other east-west European studies. The Russians did not, however, report more atopic diseases. This discrepancy might reflect different awareness of allergies in the two countries and demonstrates the need for objective markers of atopy when comparing prevalence in different populations.

Environmental nickel pollution: does it protect against nickel allergy?

The Norwegian-Russian border area is polluted because of emissions from two local Russian nickel refineries. We patch tested the general adult population on both sides of the border. Only 7.2% of the Russian women were sensitized to nickel, compared with 27.5% of the Norwegian women. We suggest that long-term exposure to nickel may have induced immunologic tolerance in the Russian population.

Patch test results in 542 patients with suspected contact dermatitis in Turkey

In this retrospective study, patch test results of 542 patients (303 female and 239 male), referred to our clinic between June 1996 and July 1999, were evaluated. All patients were patch tested with 32 allergens of an extended European standard series, 140 patients were tested with supplemental series, and 246 patients with their own substances. 280 (51.7%) patients had 1 or more positive results but allergic contact dermatitis, according to clinical relevance, was diagnosed in only 190 (67.9%) of these. Nickel sulfate was the most frequent sensitizer (19.1%), followed by potassium dichromate (11.8%), palladium chloride (9.4%), cobalt chloride (8.5%), and thiuram mix (7.7%). Frequencies of contact allergy to fragrance mix (5.5%), balsam of Peru (Myroxylon Pereirae resin) (2%), quaternium-15 (0.6%), and Kathon CG (methylchloroisothiazolinone+methylisothiazolinone) (0.2%) were relatively low, while no positive reactions were obtained to paraben mix in any case. Current clinical relevance to the present dermatitis was most frequently seen with carba mix (96.2%), thiuram mix (95.2%) and potassium dichromate (78.1%), whereas this rate was low for nickel (37.5%). In 85.8% of patients with allergic contact dermatitis, the responsible allergen was detected by testing with the extended standard series alone (18.4% identified by testing with the additional 10 allergens), in 11.6% by testing with the patients' own substances, and in 2.6% by testing with the supplemental series. Occupational contact dermatitis was diagnosed in 77 of the patients with positive reactions (27.5%), most of these being construction workers and house painters who showed relevant sensitizations to potassium dichromate, cobalt chloride, thiuram mix and carba mix. There was no statistically significant difference in the total contact sensitization rate between atopics and non-atopics, but contact sensitivity to nickel sulfate and palladium chloride was significantly higher among atopics. MOAHL index in % was: 44.1/14.2/24.9/ 54.4/2.4. In conclusion, we believe that similar large series of patients would be helpful to delineate the exact profile of contact dermatitis in Turkey.

Prevalence of nickel allergy among Finnish university students in 1995

Nickel allergy was studied in a sample of 1st-year university students starting their studies in 1995. A total of 296 subjects (72%) of 413 invited participated in the clinical examination, and 284, 96 male and 188 female, were patch tested (69%). A history of nickel sensitization was enquired for. Prick tests and serum specific IgE levels were determined. Occurrence of atopic dermatitis, hand eczema, and current exposure to metals were recorded. Nickel allergy was encountered in 39% of all female students, in 42% of females with pierced skin, and in 14% of females without pierced skin. The corresponding figures for males were 3%, 7% and 3%. In the multiple regression analysis, the risk factors for nickel allergy were female sex (OR 8.1, p<0.01), current metal exposure at examination (OR 4.1, p<0.01) and skin piercing (OR 3.6, p<0.05). Positive prick tests or elevated IgE levels to common allergens were not significantly associated with nickel allergy. In female students, the prevalence of nickel allergy has increased from 13% in 1986 to 39%. The prevalence among males has remained low at 3%. The results indicate that, in addition to skin piercing, current metal contacts are important risk factors for nickel allergy. This finding gives support to the EU Nickel Directive.

Appearance, cosmetics, and body art in adolescents

Appearance in adolescents is a means of communication, a language expressing self identity. Teenagers explore fashions to make personal statements. Teenagers are significant consumers of various toiletry and skin care products that fill their cleansing, hydrating, and photoprotective needs. They also are enthusiastic consumers of products aimed at adolescent fads, such as decorative hair and nail cosmetics. For some teenagers, the expression of individualism is achieved through body art, such as tattooing and body piercing. Areas of concern are the lack of motivation for sun protection and the risky behavior associated with body piercing and tattooing.