Ingested food in systemic allergic contact dermatitis

Is Food-Triggered Atopic Dermatitis a Form of Systemic Contact Dermatitis?

Food allergy in atopic dermatitis is mediated by complex immune interactions between genetics, diet, environment, and the microbiome. When contact between inflamed skin and food antigens occurs, contact hypersensitivity can develop. Consequently, systemic contact dermatitis (SCD) can occur after ingestion of allergenic foods or food additives in the setting of a Th2 response with CLA-positive T cells, triggering dermatitis where skin resident memory lymphocytes reside. This phenomenon explains food-triggered dermatitis. Atopy patch tests (APTs) detect sensitization to food proteins responsible for SCD, which in turn can be confirmed by oral food challenge with delayed interpretation. We summarize the literature on using APTs to identify foods for oral challenge with dermatitis as an outcome. In dermatitis patients at risk for Th2 skewing based on a history of childhood-onset flexural dermatitis, shared decision-making should include a discussion of identifying and avoiding food and food additive triggers, as well as identifying and avoiding all contact allergens, prior to initiation of systemic therapy for dermatitis.

Perspectives for Uses of Propolis in Therapy against Infectious Diseases

Propolis has gained wide popularity over the last decades in several parts of the world. In parallel, the literature about propolis composition and biological properties increased markedly. A great number of papers have demonstrated that propolis from different parts of the world is composed mainly of phenolic substances, frequently flavonoids, derived from plant resins. Propolis has a relevant role in increasing the social immunity of bee hives. Experimental evidence indicates that propolis and its components have activity against bacteria, fungi, and viruses. Mechanisms of action on bacteria, fungi, and viruses are known for several propolis components. Experiments have shown that propolis may act synergistically with antibiotics, antifungals, and antivirus drugs, permitting the administration of lower doses of drugs and higher antimicrobial effects. The current trend of growing resistance of microbial pathogens to the available drugs has encouraged the introduction of propolis in therapy against infectious diseases. Because propolis composition is widely variable, standardized propolis extracts have been produced. Successful clinical trials have included propolis extracts as medicine in dentistry and as an adjuvant in the treatment of patients against COVID-19. Present world health conditions encourage initiatives toward the spread of the niche of propolis, not only as traditional and alternative medicine but also as a relevant protagonist in anti-infectious therapy. Production of propolis and other apiary products is environmentally friendly and may contribute to alleviating the current crisis of the decline of bee populations. Propolis production has had social-economic relevance in Brazil, providing benefits to underprivileged people.

Oral provocation of patients allergic to sesquiterpene lactones with German chamomile tea to demonstrate possible systemic allergic dermatitis

BACKGROUND

Most patients with contact allergy to Asteraceae plants are patch test positive to sesquiterpene lactone mix (SLM). There are several reports among these patients of a flare-up of hand eczema after ingestion of food and beverages originating from Asteraceae plants.

AIM

To investigate whether German chamomile tea can elicit systemic allergic dermatitis.

PATIENTS AND METHODS

Individuals with or without contact allergy to SLM were patch tested with an extract of German chamomile tea. Six weeks later, they were provoked with capsules containing either freeze-dried German chamomile tea or placebo capsules containing lactose, in a double-blind, randomized study. A numerical rating scale (NRS) was used to ascertain the volunteers' opinion of their hand eczema status. The study individuals were examined to detect a possible flare-up of healed patch test reactions to chamomile.

RESULTS

None of the subjects had a flare-up of healed patch test reactions. According to the NRS, SLM-positive individuals experienced a significant worsening of hand eczema, independently of whether they received chamomile or lactose capsules.

CONCLUSION

No evidence suggestive of systemic allergic dermatitis was found.

Allergic Contact Dermatitis

Allergic contact dermatitis is common, resulting in considerable morbidity. Diagnosis is based on a thorough history, physical examination, and patch testing. Several commercially available panels of patch testing are currently used. Allergens are found in a wide variety of daily products, occupational exposures, and foods. The mainstay of treatment is avoidance of the allergen, and databases like Contact Allergen Management Program and Contact Allergen Replacement Database help patients to select products that do not contain allergens to which they are sensitized. Topical corticosteroids can be used to treat exacerbations, but should be avoided in long-term treatment.

Atopy and Sensitization to Allergens Known to Cause Systemic Contact Dermatitis

BACKGROUND

Atopic dermatitis (AD) associated with respiratory atopy may represent a form of systemic contact dermatitis (SCD), whereby AD flares after ingestion or inhalation of allergens.

OBJECTIVE

The aim of the study was to compare the prevalence of positive patch tests to allergens known to cause SCD in AD patients with and without respiratory atopy.

METHODS

This is a retrospective study of patients with AD patch tested to 23 allergens known to cause SCD. Positive patch tests were compared between AD patients with and without respiratory atopy, stratified by age and wet or dry work occupation.

CONCLUSIONS

Children and adolescents, but not adults, with AD and respiratory atopy were more likely than age-matched AD patients without respiratory atopy to have positive patch tests to these allergens (odds ratio, 2.33; 95% confidence interval, 1.13-4.79). Moreover, AD patients with respiratory atopy and engaging in wet work, but not dry work, occupations were more likely than AD patients without respiratory atopy to have positive patch tests to allergens known to cause SCD (odds ratio, 1.47; 95% confidence interval, 1.05-2.06). Thus, respiratory atopy and wet work are associated with sensitization to allergens known to cause SCD in patients with AD, and patch testing may be valuable in identifying systemic triggers of dermatitis in these patients.

Food Avoidance Diets for Dermatitis

Food allergy is relatively common in both children and adults, and its prevalence is increasing. Early exposure of food allergens onto skin with an impaired epidermal barrier predisposes to sensitization and prevents the development of oral tolerance. While immediate-type food allergies are well described, less is known about delayed-type food allergies manifesting as dermatitis. This is due, in part, to limitations with current diagnostic testing for delayed-type food allergy, including atopy patch testing. We conducted a systematic review of food avoidance diets in delayed-type food allergies manifesting as dermatitis. While beneficial in some clinical circumstances, avoidance diets should be used with caution in infants and children, as growth impairment and developmental delay may result. Ultimately, dermatitis is highly multifactorial and avoidance diets may not improve symptoms of delayed-type food allergy until combined with other targeted therapies, including restoring balance in the skin microbiome and re-establishing proper skin barrier function.

Systemic contact dermatitis to foods: nickel, BOP, and more

Systemic contact dermatitis (SCD), a cutaneous reaction that is a direct manifestation of systemic exposure to a known allergen in a sensitized individual, has been increasingly recognized as a cause of persistent cutaneous contact dermatitis that is refractory to conventional therapies. While SCD in response to drugs has been described well in the literature, SCD to allergens in common foodstuffs is a less well-articulated phenomenon. Several foods that are universally consumed throughout the world contain potent allergens including nickel, balsam of Peru, trace metals, urushiol, and sesquiterpene lactones as well as a host of others that may cause a distinctive clinical picture. In this review article, the authors review the typical presentation and prevalence of SCD to foods, pathophysiology, the most common offensive ingestible food allergens, several appropriate diets, and effectiveness of dietary avoidance for situations in which SCD is suspected.

Spice allergy

OBJECTIVES

To provide a review on spice allergy and its implementation in clinical practice.

DATA SOURCES

PubMed searches were performed using spice allergy as the keyword for original and review articles. Selected references were also procured from the reviewed articles' references list.

STUDY SELECTION

Articles were selected based on their relevance to the topic.

RESULTS

Spices are available in a large variety and are widely used, often as blends. Spice allergy seems to be rare, reportedly affecting between 4 and 13 of 10,000 adults and occurring more often in women because of cosmetic use. No figures were available on children. Most spice allergens are degraded by digestion; therefore, IgE sensitization is mostly through inhalation of cross-reacting pollens, particularly mugwort and birch. The symptoms are more likely to be respiratory when exposure is by inhalation and cutaneous if by contact. Studies on skin testing and specific IgE assays are limited and showed low reliability. The diagnosis primarily depends on a good history taking and confirmation with oral challenge. The common use of spice blends makes identifying the particular offending component difficult, particularly because their components are inconsistent.

CONCLUSION

Spices are widely used and contain multiple allergens, yet spice allergy is probably markedly underdiagnosed. There is a need for reliable skin testing extracts and serum specific IgE assays. Currently, the diagnosis depends on a good history taking and well-designed titrated challenge testing. Until immunotherapy becomes developed, treatment is strict avoidance, which may be difficult because of incomplete or vague labeling.

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.

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.

Systematized contact dermatitis and montelukast in an atopic boy

Upon ingestion, the artificial sweetener, aspartame is metabolized to formaldehyde in the body and has been reportedly associated with systemic contact dermatitis in patients exquisitely sensitive to formaldehyde. We present a case of a 9-year-old Caucasian boy with a history of mild atopic dermatitis that experienced severe systematized dermatitis after being started on montelukast chewable tablets containing aspartame. Patch testing revealed multiple chemical sensitivities which included a positive reaction to formaldehyde. Notably, resolution of his systemic dermatitis only occurred with discontinuation of the montelukast chewables.

[Hematogenous contact eczema induced by foods]

Oral ingestion or parenteral administration of certain contact allergens may elicit eczematous skin reactions "from inside" in sensitized individuals; this phenomenon has been termed "systemically-induced eczema" or "hematogenous contact eczema". There is a wide range of clinical features from polyetiological dyshidrotic hand and foot eczema to baboon syndrome. The most important contact allergens known to elicit systemically-induced contact eczema are metal salts, drugs, phytoallergens and balsam of Peru. Diagnosis is based on proof of delayed type hypersensitivity by patch testing and oral challenge. Until more and better data is acquired, special diets (for instance low nickel) should be instituted only in carefully selected patients.

Adverse food reactions by skin contact

The skin is very much exposed to food contact, both in the occupational and nonoccupational settings. Through such an exposure, adverse reactions can occur that may be irritant or immunologic. Both such types of reactions are particularly common in children with atopic dermatitis. Immunologic reactions can be immediate (immunoglobulin E-mediated) or delayed (cell-mediated), and can be localized or systemic. The latter can be life-threatening, even following trivial exposure. Clinical and experimental data are accumulating to indicate that epicutaneous exposure to food can induce de novo systemic immunoglobulin E sensitization.

Experimental systemic contact dermatitis from nickel: a dose-response study

Systemic contact dermatitis is usually seen as flare-up of previous dermatitis or de novo dermatitis similar to allergic contact dermatitis. Although systemic contact dermatitis from medicaments is a well-established entity, the existence of clinically relevant systemic reactions to oral nickel exposure, in particular systemic reactions to nickel in the daily diet, remains controversial. Several studies have shown that oral exposure to nickel can induce systemic contact dermatitis in nickel-sensitive individuals. In most of these studies, however, the exposure dose of nickel used has been considerably higher than the nickel content in the normal daily diet. The aim of the current investigation was to study dose-response dependency of oral exposure to nickel. In a double-blind, placebo-controlled oral exposure trial, 40 nickel-sensitive persons and 20 healthy (non-nickel-sensitive) controls were given nickel sulfate hexahydrate in doses similar to and greater than the amount of nickel ingested in the normal Danish daily diet. The nickel content in urine and serum before and after oral exposure was measured to determine nickel uptake and excretion. The influence of the amount of nickel ingested on the clinical reactions to oral exposure and on nickel concentrations in serum and urine was evaluated. Among nickel-sensitive individuals, a definite dose-response dependency was seen, following oral exposure to nickel. 7 of 10 nickel-sensitive individuals had cutaneous reactions to oral exposure to 4.0 mg nickel, an amount approximately 10 times greater than the estimated normal daily dietary intake of nickel. 4 of 10 nickel-sensitive individuals had cutaneous reactions to 1.0 mg nickel, a dose which is close to the estimated maximum amount of nickel contained in the daily diet. 4 of 10 nickel-sensitive individuals reacted to 0.3 mg nickel or to the amount equivalent to that contained in a normal daily diet, and 1 of 10 reacted to a placebo. None of the 20 healthy controls had cutaneous reactions to 4.0 mg nickel or to a placebo. Prior to oral exposure, there was no measurable difference in the amount of nickel in the urine or serum of nickel-sensitive persons and healthy controls. Following the oral challenge, the nickel content in the urine and serum of both nickel-sensitive and healthy control individuals was directly related to the dose of nickel ingested.

Adverse reactions to foods

Allergic reactions to foods represent a prominent, actual and increasing problem in clinical medicine. Symptoms of food allergy comprise skin reactions (urticaria, angioedema, eczema) respiratory (bronchoconstriction, rhinitis), gastrointestinal (cramping, diarrhea) and cardiovascular symptoms with the maximal manifestation of anaphylactic shock. They can be elicited by minute amounts of allergens. The diagnosis of food allergy is done by history, skin test, in vitro allergy diagnosis and--if necessary--oral provocation tests, if possible placebo-controlled. Avoidance of respective allergens for the allergic patient, however, is often complicated or impossible due to deficits in declaration regulations in many countries. Increasing numbers of cases including fatalities, due to inadvertent intake of food allergens are reported. It is therefore necessary to improve declaration laws and develop methods for allergen detection in foods. Allergens can be detected by serological methods (enzyme immunoassays, in vitro basophil histamine release or in vivo skin test procedures in sensitized individuals). The problem of diagnosis of food allergy is further complicated by cross-reactivity between allergens in foods and aeroallergens (pollen, animal epithelia, latex etc.). Elicitors of pseudo-allergic reactions with similar clinical symptomatology comprise low-molecular-mass chemicals (preservatives, colorings, flavor substances etc.). For some of them (e.g. sulfites) detection assays are available. In some patients classic allergic contact eczema can be elicited systemically after oral intake of low-molecular-mass contact allergens such as nickel sulfate or flavorings such as vanillin in foods. The role of xenobiotic components in foods (e.g. pesticides) is not known at the moment. In order to improve the situation of the food allergic patient, research programs to elucidate the pathophysiology and improve allergen detection strategies have to be implemented together with reinforced declaration regulations on a quantitative basis.

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

BACKGROUND

The north-Norwegian population of Sør-Varanger lives close to 2 Russian nickel smelters.

OBJECTIVE

We studied the importance of the local nickel pollution, as well as ear piercing and atopic dermatitis, on the prevalence of nickel allergy in Sør-Varanger.

METHODS

We patch-tested 1767 adults who were randomly selected from 2 different cross-sectional studies; in Sør-Varanger and the reference city of Tromsø, which has no nickel-polluting industry.

RESULTS

Nickel allergy was diagnosed in 27.5% and 31.1% of the women in Sør-Varanger and Tromsø, respectively, and in 5.1% and 5.0% of the men. In women, ear piercing was a strong risk factor (relative risk = 3.30; 95% confidence interval = 2.01 to 5.43). A history of atopic dermatitis was not associated with nickel sensitization. We found no increased risk of nickel allergy in Sør-Varanger compared with Tromsø in adjusted multivariate analyses.

CONCLUSION

The high prevalence of nickel allergy found in Sør-Varanger could not be attributed to pollution from the nearby nickel industry.